What is Infertility

Infertility is defined by the World Health Organization (WHO) as: “the inability of a couple to achieve conception or bring a pregnancy to term after a year or more of regular, unprotected sexual intercourse.”

Reduced fertility or Subfertility

Complete infertility is unusual. Much more common is reduced fertility in one or both partners. For this reason, some doctors prefer to use the term subfertility, which describes a delay or difficulty in getting pregnant.

Primary Infertility

The failure of a couple to have any children at all is termed primary infertility.

Secondary Infertility

Couples who have already conceived and now are finding it difficult to achieve conception again.

A lot of questions will come to your mind when you have been unable to achieve conception.

Why am I not getting pregnant naturally?

For a woman to conceive, intercourse must take place around the time when an egg is released from ovary; the sperm count should be normal, your hormones must be balanced and the egg and the sperm must meet, ie, your Fallopian Tubes must be open. If the couple is not using contraception and having intercourse regularly, 85 - 90 % of couples will conceive within two years.

When am I most fertile?

 If your periods are regular, every 28 - 30 days, you probably ovulate around 14 th day of the cycle. Eggs live and can be fertilised for 12-24 hours after being released, and sperm can stay alive and active in your body for 12-48 hours after ejaculation, so you don't have to have intercourse at the exact moment of ovulation to get pregnant.

 How usual is it to have problems conceiving?

An estimated one in seven couples have difficulty conceiving.  

Causes of Infertility

Infertility is not just a woman's problem. It strikes men and women almost equally. About 32 per cent of cases can be attributed to men, another 32 per cent to women, and 17 per cent to a combination of factors affecting both partners. This leaves about 19 per cent of couples where the cause of infertility remains unexplained.

Female Infertility

1: Ovulation Failure - 40 to 50 %

2: Tubal Damage - 25 %

3: Endometriosis-10 %

4: Miscellaneous Causes - 15%

1 : Failure to Ovulate

Ovulatory disorders are one of the most common reasons why women are unable to conceive, and account for 40 to 50 % of women's infertility.  

The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation.  There are three main sources causing this problem

1. Polycystic Ovarian Syndrome ( PCOD )

Here all the hormones are within normal limits but they do not work in synchrony.

2. Malfunction of the hypothalamus or the pituitary glands. 

The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation.  If the hypothalamus fails to trigger and control this process, immature eggs will result. The pituitary's responsibility lies in producing and secreting FSH and LH.  The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced.  This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.
 
3. Ovarian Failure
 

Premature Menopause
 Some women cease menstruation and begin menopause before normal age.  This affects around 1 % of the population.  There is a genetic possibility for this condition

Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur.  

4. Follicle Problems

Although currently unexplained, "unruptured follicle syndrome" occurs in women who produce a normal follicle, with an egg inside of it, every month yet the follicle fails to rupture.  The egg, therefore, remains inside the ovary and proper ovulation does not occur.

 

 Tubal Diseases

Tubal disease affects approximately 25% of infertile couples and varies widely, ranging from mild adhesions to complete tubal blockage.  The main causes of tubal damage include:

(1) Infection
     Caused by both bacteria and chlamydia and usually transmitted sexually, these infections commonly cause inflammation resulting in scarring and damage.  A specific example is Hydrosalpnix, a condition in which the fallopian tube is occluded at both ends and fluid collects in the tube.

Tuberculosis is a very common cause of tubal block in the developing countries.

(2) Abdominal Diseases
      The most common of these are appendicitis causing inflammation of the abdominal cavity which can affect the fallopian tubes and lead to scarring and blockage.

(3) Previous Surgeries
     This is an important cause of tubal disease and damage.  Pelvic or abdominal surgery can result in adhesions that alter the tubes in such a way that eggs cannot travel through them.

(4) Ectopic Pregnancy
      This is a pregnancy that occurs in the tube itself and, even if carefully and successfully overcome, may cause tubal damage .

(5) Congenital Defects
      In rare cases, women may be born with tubal abnormalities.

Endometriosis

Approximately 10% of infertile couples are affected by endometriosis and 30-40% of patients with endometriosis are infertile.  This is two to three times the rate of infertility in the general population. 

This condition is characterized by excessive growth of the lining of the uterus, called the endometrium.  Growth occurs not only in the uterus but also elsewhere in the abdomen, such as in the fallopian tubes, ovaries and the pelvic peritoneum.  A  diagnosis can only be made by diagnostic laparoscopy,  The symptoms often associated with endometriosis include heavy, painful and long menstrual periods, urinary urgency, rectal bleeding and premenstrual spotting.  Sometimes, however, there are no symptoms at all.  

Miscellaneous Factors

  At least 10% of all cases of female infertility are caused by an abnormal uterus.  Conditions such as fibroid, polyps, and adenomyosis may lead to obstruction of the uterus and Fallopian tubes.
 

•   Congenital abnormalities, such as septate uterus, may lead to recurrent miscarriages or the inability to conceive.
   
•   Approximately 3% of couples face infertility due to problems with the cervical mucus.  The mucus needs to be of a certain consistency and available in adequate amounts for sperm to swim easily within it. 

 

 Male Factor

 

Sperm defects such as absent or sumnormal sperms are caused by a number of causes, some proved, some stil not proved.

 

Subnormal sperms

 

1. Unknown reason

 

This is, surprisingly, the most common cause.

 

2. Varicocele

A varicocele is an abnormally enlarged and twisted (varicose) vein in the spermatic cord that connects to the testicle. Varicoceles are found in 15 - 20% of all men and in 25 - 40% of infertile men, although it is not clear how or even if they affect fertility. They tend to occur more commonly (85%) on the left side. Some theories supporting their possible effect on infertility include:

Varicoceles may partially obstruct the passages through which sperm pass.

Varicoceles may elevate temperature in the testes.

Varicoceles may produce higher levels of nitric oxide, a substance that has beneficial effects on blood flow and other functions but which might, in excess, injure sperm.

Varicoceles may block oxygen supply to the sperm.

Varicoceles have been associated with abnormalities in cellular material in the sperm. One study suggested that some men may have genetic defects that cause both varicoceles and impaired sperm, rather than the varicocele itself causing infertility.

Role pf varicpcele surgery is controversial. A few well-conducted studies on repair of varicoceles suggest that the procedure does not improve pregnancy rates. Their effect on fertility remains unclear.

3.Retrograde Ejaculation

Retrograde ejaculation occurs when the muscles of the urethra do not pump properly during orgasm and sperm are forced backward into the bladder instead of forward out of the urethra. Sperm quality is often impaired.

4. Autoantibodies

Autoimmunity is a condition in which antibodies of the immune system attack specific cells in the body, mistaking them for foreign invaders. In the case of male infertility, these so-called autoantibodies ("self" antibodies) target the sperm. Antibodies bind to specific parts of the sperm, such as the head or tail and, depending on the site of attachment, cause various problems:

Sperm may stick together (agglutinate)

They may fail to interact with cervical mucous

They may be unable to penetrate the egg.

5. Mumps

When mumps develops after puberty, it damages the testicles in 25% of men afflicted with the disease.

6. Temporary causes of Low Sperm Count

Nearly any major physical or mental stress can temporarily reduce sperm count.

Emotional Stress.

Testicular Overheating. Overheating, such as from high fevers, saunas, and hot tubs, may temporarily lower sperm count. Persistent exposure to high temperatures during work may impair fertility.

Substance Abuse. Alcohol does not appear to affect fertility, unless it is so abused that it causes liver damage.

Smoking. Smoking impairs sperm motility, reduces sperm lifespan, and may cause genetic changes that affect the offspring. One trial found that men or women who smoke have lower success rates with assisted reproductive technologies. 

Malnutrition and Nutrient Deficiencies. Deficiencies in certain nutrients, such as vitamin E, vitamin C, selenium, zinc, and folate, may be particular risk factors for infertility. This needs further scientific proof.

Obesity. Obesity may be a risk factor for male infertility. A 2006 epidemiological study found that a 20-pound increase in a man’s weight increased the chance for infertility by about 10 percent.

Absent Sperms

There are two types.

1. Sperms are not being formed : Testicular Failure ( Non Obstructive Azoospermia )

Primary Testicular Failure

Mumps

Undescended Testes

Radiation treatment

Cancer Chemotherapy

2. Sperm path obstructed :( Obstructive Azoospermia )

Conginital Bilateral Abscence of Vas Deference ( CBAVD)

Tuberculosis

Sexually Transmited Diseases

Surgery ( Vasectomy, Hernia or Hydrocele repair )

Unexplained Infertility

Here, apparently no cause for the problem could be established after conventional methods of investigations.

What are the Causes of Unexplained Infertility?
There may be certain factors at play when a couple is experiencing difficulty achieving pregnancy.

Abnormal Fallopian Tubes. Even the most seemingly miniscule abnormality in fallopian tubes can lead to unexplained infertility. That is because fallopian tubes are not mere conduits to connect ovaries to the uterus but they have to do some work during the process. The fimbria are finger-like projections located at the ends of each fallopian tube. Their job is to get a hold of your ovaries, so as to coax your egg inside. Your fallopian tubes also contain tiny hairs called cilia that work to direct your egg down into your uterus. If there are problems with either the fimbria or cilia, that could prevent your eggs from being fertilised. The inner lining of the tube has to produce certain secretions which will nurture the egg and the developing embryo.
Abnormal Eggs. Even though we see ovulation on the sonography the quality of the can never be ascertained. The egg may have chromosomal problems, impenetrable zona.

Weak Sperm. In order to become fertilised, sperm must be able to break through the outer shell of your egg. In certain cases, even seemingly healthy-looking sperm are not strong enough to penetrate through the egg shell,and thus, cannot create an embryo.

Luteinised Unruptured Follicle (LUF) Syndrome.  LUF is caused when the follicles become corpus luteum before releasing the egg – in effect, trapping it inside. Consequently, ovulation is blocked. The biochemical tests would suggest ovulation but in fact, there is no ovulation.

Abnormal Luteal Phase. Once the egg has been released from the ovaries, a new phase of the menstrual cycle begins – the luteal phase. It is during this phase that the corpus luteum begins to produce progesterone – the hormone responsible for preparing the endometrial lining for implantation. If, however, progesterone levels rise too quickly or too slowly, or if the hormone was not produced for a long enough period, the endometrium will not be properly prepared for implantation.

Immunological problems. Although your immune system is designed to protect you from any invading organisms, it can sometimes become confused, and start to attack healthy cells. In some cases, a woman’s immune systems can begin to attack her own eggs. The same thing could also be happening to the male partner, causing sperm to stick together, therefore making them unable to move.

 

Approach to Infertility