Infertility

Infertility may be caused by more than one factor. Some causes are easily found and treated, while others are not. In some cases, no cause can be found in either partner. If pregnancy has not been achieved after 12 months of having regular sex, infertility investigations should start, as an underlying infertility problem may be discovered.

CONCEPTION

For healthy, young couples, the chances are about 20% that a woman will become pregnant during any one menstrual cycle. This figure starts to decline in a woman's late 20s and early 30s and decreases even more after age 35. A man's fertility also declines with age, but not as early.

Ovulation is the release of an egg from one of the ovaries. In an average 28-day menstrual cycle, ovulation occurs about 14 days after the first day of your last period. Once an egg is released, it is able to be fertilized for about 12-24 hours. Conception can occur if you have sex during or near the time of ovulation.

After a couple has sex, the man’s sperm is released into the vagina and travel up through the cervix and out into the tubes. Sperm can live in the woman's fallopian tubes for 3 days or more. If the sperm and egg join, fertilization occurs.

The fertilized egg then moves through the tube into the uterus. It becomes attached there and begins to grow. All of these events must take place for pregnancy to occur. Infertility will result if any of these events fail to occur.

CAUSES OF INFERTILITY

• Disorders of ovulation (expressed by menstrual disorders, hirsuitism or galactorrhea)
• Tubal disease (it may occur after pelvic & abdominal surgery or pelvic infection)
• Endometriosis
• Cervical factors
• Male factor
• Coital problems (issues related to frequency and psychological problems)

TESTS FOR INFERTILITY

Investigation for infertility includes both partners. The basic process of fertility evaluation requires few menstrual cycles to be completed. The investigations include:

• Discussion about how often and when you have sex
• Medical history and physical examination for both partners
• Check for ovulation
• Semen analysis
• Tests to check for a normal uterus and open fallopian tubes

Infertility investigations for the woman:

The history will focus on the following issues:

• Menstrual pattern (irregular periods may imply ovulation disorder)
• Pain during or before menstruation or during intercourse (these could be symptom of endometriosis)
• History of sexually transmitted diseases (as this may suggest pelvic infection disease)
• History of abdominal operations (as this may imply intrabdominal adhesions).

The physical examination will look for details of the secondary female characteristics as for evidence of acne and hirsuitism (signs of polycystic ovaries).

Blood tests:

A blood test taken in the second half of the menstrual cycle can measure progesterone to show if ovulation has occurred as this hormone is produced from the ovaries after a woman ovulates. Follicle stimulating hormone (FSH) and luteinising hormone are also measured at the beginning of the menstrual cycle to evaluate the reserves of the ovaries to produce good quality eggs. If there are period irregularities, prolactin and thyroid function test may also performed.

Post-coital test (PCT)

This test examines under microscope the number and the function of sperm in the cervical mucus six to twelve hours after the couple had intercourse.

Procedures:

Transvaginal Ultrasound:

This procedure uses a thin long ultrasound probewhich is inserted into the vagina and produce images of pelvic organs. Although it is not a pleasant procedure, is not painful and is well tolerated by the majority of women. It helps to evaluate the ovaries and uterus.

Hysterosalpingography (HSG):

This test is an X-ray that shows the inside of the uterus and fallopian tubes. In most cases, it is done right after the menstrual period. A small amount of dye is placed in the uterus through a thin tube inserted through the cervix. Then, an X-ray is taken. The fluid outlines the inside of the uterus and shows (by a spill of the fluid out of the tubes) whether they are open. You may be given pain relief for this procedure.

Hysteroscopy:

This procedure permits the doctor to evaluate the inside of the uterus. A thin telescope-like device, called hysteroscope, is placed through the cervix. The inside of the uterus is filled with a liquid or gas to permit the hysteroscope to have a good quality of picture. With this procedure, the doctor can also correct some problems like removing polyps, submucosal fibroids or uterine septum.

Laparoscopy:

A small telescope-like device, called a laparoscope, is inserted under general anaesthesia through a small cut (about 1cm or less) at the lower edge of the umbilicus. The doctor can look at the tubes, ovaries, and uterus. The doctor can look for pelvic problems, such as endometriosis or scar tissue. Fluid is placed into the uterus to see if the fluid spills from the ends of the tubes. This shows if the tubes are open or blocked. By adding two or three extra cuts at the lower abdomen, the doctor can sometimes perform an operation to correct the problem of infertility.

Infertility investigations for man:

A semen assessment is the key investigation of male fertility. A fresh sample is needed and it may need to be repeated more than once.

The semen sample will be studied for the following factors:

• Number
• Morphology
• Movement
• Signs of infection

If the sperm appears to be unsatisfactory, the male partner may consult an urologist before the couple considers assisted reproductive methods of conception.

TREATMENT

General measures

Fertility can often be affected by lifestyle issues. The frequency that the couple are having sex is a very important factor, which many times is undervalued. Regular sex 2-3 times a week is important in order to achieve the best chances for conception. Both partners should stop or at least reduce bad habits like smoking and drinking. Men should avoid hot showers and tight underwear and women may need to lose or gain weight.

Surgery

Surgery may be done to open fallopian tubes or repair other problems of the reproductive organs. It may be done to remove growths such as polyps or fibroids. Surgery also may be done to remove scarring that occurred as a result of a previous surgery, infection, or endometriosis. If endometriosis is found, surgery may be done to treat it. Success rates depend on the nature and extent of the problem.

Ovulation Induction

If the woman has a problem with ovulation, certain medications can help her to ovulate. She also can be given medication to increase the number of eggs released.

The medicine used most often is clomiphene which is a pill given by mouth to help women who have problems with ovulation to release an egg. A number of treatment cycles may be needed, and dosage and medication may need to be altered.

If pregnancy does not occur after several treatment cycles with clomiphene, other more potent treatments may be tried. This is in the form of hormonal injection which stimulates the ovaries to mature and produce eggs. Blood tests and ultrasound often are used to monitor the effects of this treatment. This is important in order to avoid certain side-effects of this treatment such as multiple pregnancy and ovarian hyperstimulation syndrome. This syndrome may present if too many eggs develop at the same cycle and may cause painful swelling of the ovaries and fluid in the abdomen and lungs. In this case it may be decided to stop the treatment in order to reduce the chance of this syndrome occurring.

Most women who take ovulation-induction drugs respond to the treatment and begin to ovulate regularly. If no other problem requires treatment, more than half become pregnant within 6 cycles. If a woman still hasn't started ovulating, she may have special investigations to find the reason.

Assisted Reproductive Methods

Assisted reproductive technology (ART) includes treatments that involve a laboratory which with technical means, improve the sperm quality or treat human eggs and sperm to help an infertile couple conceive a child.

The following are some of the ART treatments available to couples trying to conceive.

Intrauterine Insemination

With this method, at the time of ovulation, the doctor using a fine tube, places the partner’s sperm into the woman's uterus. In most cases, the sperm are treated in a lab to increase the chances for fertilization.

In Vitro Fertilization

With in vitro fertilization (IVF), eggs from the woman and sperm from a man are fertilized outside the body in a lab. The fertilized egg then is placed in the woman's uterus to grow.

The eggs are removed from the ovary just before ovulation. Medication is used most of the time to help the ovaries to produce more than one egg. Eggs usually are removed by inserting a needle through the vagina into the ovary under ultrasound guidance. The eggs are withdrawn through the needle. Analgesia or a sedative may be given.

The eggs then are combined with sperm and are observed to see if fertilization occurs.

A few days later, one or more fertilized eggs (embryos) are placed in the woman's uterus through her vagina. This is called embryo transfer. The unused fertilized eggs can be frozen and stored for later use.

The success rate of IVF depends on the woman's age and the reason for the infertility.

Its possible side effects are the same as those from ovulation medications.

Intracytoplasmic Sperm Injection

With intracytoplasmic sperm injection (ICSI), one sperm is placed directly into an egg to fertilize it. First, sperm are removed from the semen. One sperm is injected into each egg's center. They are checked to see if the eggs are fertilized. Once fertilized, the eggs are placed in the woman's uterus to grow, or they are frozen for later use. This technique is fairly new and little is known about any long-term effects.