Understanding Infertility

UNDERSTANDING INFERTILITY

 

BEGINNING OF A NEW LIFE Life begins with the ovulation, when a ripe egg is being released from the ovary It moves down the fallopian tube ready to be fertilised. 

During sexual intercourse, millions of sperm are released into the vagina and made their way to the fallopian tubes.

Fertilisation takes place when a sperm enters the egg and fuses with it. The fertilised egg then enters the womb and embedded itself in the lining of the womb. This is called implantation. Here it continues to grow into a healthy baby whom will be born nine months later.

INTRODUCTION

There are many reasons why a couple may have difficulty getting pregnant. 25 years ago, the median age of woman delivery her first baby was early twenties and now, it is 28. Careers and later marriages forced women to conceive later in life when natural fertility declines.

Approximately one in six couples will experience infertility problems sometime in their reproductive lives. Individual medical problems in both male and female are still the leading cause of fertility problems. For these people, there is an intense experience of sufferings and despair associated with the prospect that they may never have children or may be unable to have their own biological offspring.

The general practitioner is normally the first person to be consulted about such problems. He or she can therefore play an important role in organizing the initial investigations and treatment. Support and counseling can also be given during what can be a very stressful period. Couples may be referred to specialists for dedicated treatment. The specialist’s choice of one particular treatment will depend on the type (or cause) of infertility which investigations revealed.

Advances in fertility treatment have helped many infertile couples to have a family.

UNDERSTANDING FERTILITY PROBLEMS

The term infertility is generally used when a couple fails to conceive after they have tried to have a baby for about a year. Under normal circumstances, 80% of women who have regular sex without using contraception will get pregnant in the first year of trying. Age, lifestyle and biological factors can all dramatically lower chances of conceiving.

Since fertility normally declines with age, fertility evaluation is recommended for couples over thirty years who have not conceived after six months of regular unprotected sex. Couples under thirty should be given medical counseling if they have not conceived after one year of trying. Sometimes, simple advices such as having regular intercourse enable them to overcome their problem.

Historically, infertility has largely been attributed to the female. However, in reality, it affects men and women almost equally. Female-related factors account for 40% of infertility, with male-related factors accounting to another 40%. A combination of male and female-related factors account for about 10% of infertility, while the remaining 10% is due to unexplained causes. Therefore, it is important to discuss treatment with both partners so that they will understand the problems (causes) of their infertility.

The process used to identify fertility problems is referred to as the fertility work-up. It includes a variety of tests performed to determine exactly where the problem or problems lie so that they may be appropriately treated.

REASONS FOR FERTILITY PROBLEMS

There are so many reasons why a couple may have difficulty getting pregnant. A detailed medical and personal history from both partners should be obtained to evaluate the couple’s fertility. Infertility in broad term is classified into four main reasons and the fertility evaluation should be designed to question the following:

1) MALE INFERTILITY- Is there a sperm problem?

Male infertility may be caused by a number of factors, including problems with sperm production, blockage of the sperm delivery system, antibodies against sperm, injury to the testis, problems relating to hormone production, anatomical problems or the presence of varicose vein around the testis (varicocele). All of which may affect sperm quantity and quality. Past illnesses, infections, various diseases and medications can also cause infertility.

MALE FERTILITY TESTS

  • Semen analysis – check quantity and quality of sperm

  • Serum FSH, LH, Testosterone – information on testicular, function

  • Urinalysis – check for infection and retrograde ejaculation

  • Other tests of sperm and semen – test the fertilising capacity of sperm

  • Antisperm antibody measurement – Check presence of immunological factor

  • Testicular biopsy – check on the presence of spermatogenesis

  • Other diagnostic tests – e.g. Ultrasound to eliminate presence of varicocele

2) FEMALE INFERTILITY- Is there a problem with ovulation?

Egg production and ovulation occurs regularly. Usually, if a woman is menstruating regularly, she will be ovulating. But this is not always true. A woman can be oligoovulatory (irregular ovulation) or anovulatory (no ovulation) and still have periods. However, under such circumstances, her period is generally either irregular (oligomenorrhea) or absent altogether (amenorrhea). As a result, women may require a number of tests to determine ovulatory status.

OVULATORY TESTS

  • Basal body temperature chart – basal body temperature increases just before ovulation

  • Post Coital testing – reveals mucus suitability for sperm at the time of ovulation

  • Urinary LH testing – increases just before ovulation

  • Serum FSH/LH/ Prolactin testing – normal levels indicate regular ovulation

  • Pelvic Ultrasound – detects follicular growth

3) CAN THE EGG AND SPERM MEET?

Infertility is sometimes caused by factors in either the man or woman that make it difficult for the sperm and egg to come together, the later is essential for fertilisation to occur. Factors which cause these blockage include physical (blocked fallopian) and physiological (unfavorable immunological environment toward the sperms)

FERTILISATION TESTS 

  • cervical mucus testing – test on timing of ovulation

  • Postcoital testing – check on sperm survivability 

  • Hysterosalpingography – check on fallopian tube potency

  • Diagnostic laparoscopy – to ensure normal pelvic anatomy and absence of endometriosis or scar tissues around tubes and ovaries

  • Hysteroscopy – to ensure normal uterine anatomy and confirmation of endometrium response to hormones

4) CAN IMPLANTATION OCCUR AND BE MAINTAINED?

Infertility may be linked to problems in the development of the endometrium and the hormones that work to maintain the pregnancy. These types of problems are often referred to as luteal phase defects. Several tests can be used to identify luteal phase defect.

IMPLANTATION TESTS

  • Serum progesterone testing – high level is required for implantation

  • Endometrium biopsy – to ensure normal endometrium development for implantation and maintenance of pregnancy

  • Ultrasonography – to check presence of implantation sac.

Once a diagnosis has been reached, appropriate action can be taken to institute treatment (e.g. change of sexual technique, hormone therapy or simple artificial insemination). Patients may be referred to specialist for dedicated surgical treatment and advanced reproductive techniques (Gamete intra-fallopian tube transfer, In-vitro fertilisation, assisted fertilisation such as ICSI etc).

 

TREATMENT FOR INFERTILITY

Male treatment

Infections can be treated with antibiotics. For low sperm production, hormone injections/medication can be given. In the case of blockage of the sperm ducts, hernia or varicose veins, corrective surgery can be performed.

Female treatment

For the women who fail to ovulate, fertility drugs may be given to induce ovulation. In the case of blocked fallopian tubes, corrective surgery can be performed. Endometriosis may be treated with drugs and in some cases, surgery may be necessary.

In some cases, infertility problem cannot be treated. New procedures designed to bypass the fertility problem can be used to allow conception to occur. The type of treatment procedure chosen will depend on the diagnosis which investigations revealed. The various advanced assisted conception procedures include the following:

  • Artificial insemination (Intracervical insemination, ICI or Intrauterine insemination, IUI) – transfer of processed sperm into the cervical canal or uterine cavity to overcome male factor infertility, hostile cervical mucus, unexplained infertility and mild endometriosis in the female

  • Gamete intrafallopian tube transfer (GIFT) – replacing eggs and sperm into the fallopian tube for unexplained infertility

  • Invitro fertilisation (IVF) – allowing fertilisation to take place in the laboratory for blocked or damaged tubes, male factor infertility and endometriosis

  • Gamete (sperm and egg) donation – using donated gametes for males with severe sperm disorders or for men and women who are unable to produce their own gametes

  • Assisted fertilisation by intracytoplasmic sperm injection treatment – injecting the sperm into the egg. This treatment has revolutionised annt for most difficult cases of male infertility

 

ARTIFICIAL INSEMINATION (Intro Cervical Insemination/Intro Uterine Insemination)

This technique is the easiest form of non-surgical office procedure assisted conception technique and should be used as first line treatment before embarking onto other more advanced assisted conception techniques. This IUI procedure if done properly is fairly painless and very similar to a Pap smear test. This procedure is most suitable for couples with the following problems:

  • Unexplained infertility

  • Premature ejaculation • Coitus problems

  • Mild sperm factor • Hostility of the cervical mucus to sperm

  • Immunological problems.

  • Mild endometriosis

There should be no obvious female reproductive abnormalities except for mild endometriosis where tissue from womb lining is found elsewhere in the reproductive tract.

Most IUI pregnancies occur in the first 3 to 4 attempts, especially in younger women with husband having normal semen. However, after a maximum of six cycles, the therapy should be supplemented by ovulating inducing agents to improve the chances of pregnancy.

In this IUI procedure, sperm is usually collected through masturbation and enhanced using special medium containing enhancing substrates. Enhanced sperm is then either placed into the cervical canal (ICI) or high up in the uterus (IUI) of the female through a fine catheter thereby encourages fertilisation. Placing the sperm directly into the cervical canal or uterus increases the number of sperm that may move up the reproductive tract. Under normal conditions, less than 10% of all the sperm deposited naturally in the vagina reaches the cervix. Only about 200 sperm will be successful in making their way to the fallopian tubes to meet the egg. 

If the woman has poor or no mucus, the doctor may insert the sperm directly into the uterine cavity thus increases the chances of fertilisation. It is a relatively simple and painless procedure that is performed in the doctor’s clinic without any anaesthesia. Best results are obtained when the insemination coincides with ovulation in the natural cycle or induced by fertility drugs in form of tablets or injections.

Clomiphene citrate is the common oral drug used to induce ovulation. Dosage starts from 50 mg daily for 5 days from Day 6 to 9 of the menstrual cycle and if there is no ovulation, some doctors use incremental dosage up to 200 mg to get a better response.

Fertility hormones like follicular stimulating hormone (FSH) and human menopausal gonadotropins (HMG) are the common drugs used to induce ovulation. They come in the form of injections and are commonly used by fertility specialists. Patients on injectables require more stringent monitoring of ovarian follicular development to avoid ovarian hyperstimulation syndrome and to reduce the risk of multiple pregnancies, a complication that may require hospitalisation.

Ultrasound scanning or a simple urinary LH (or blood) test can be used to monitor treatment and to detect LH surge suggesting ovulation in 24 to 36 hours.

Success rate for IUI with husband’s semen is in the range of between 14% to 20% per cycle depending on the indication, type of treatment cycles and the age of the women. The cumulative fecundity can reach as high as 50% after several cycles. The rate for multiple pregnancies is 23-30%.

In the case of IUI with donor insemination, the pregnancy rate is in the range of 26% to 30% per cycle.

Success rate appears to be higher in the young female age group, short duration of infertility, secondary infertility, a higher number of motile sperm inseminated and dual inseminations in the same treatment cycle.

Read more here on the Frequently Asked Questions on Intrauterine Insemination.

 

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