Infertility

A delay in conception is one of the most common reasons that a couple will consult their doctors. Infertility is defined as the inability of a person to achieve fruitful pregnancy through natural means despite having frequent, unprotected, regular intercourse for almost 12 months. Infertility may be primary or secondary, couples have not had a child together in primary infertility and in secondary infertility, they failed to conceive following a previous pregnancy (although either partner may have conceived in a different relationship).

Female causes of infertility

Female factors contribute to around 25% of infertility cases. Most of the causes of infertility are asymptomatic and require a visit to OB-GYN for proper diagnosis and management. The factors that contribute to female infertility are:

- Age

The most important factor affecting fertility is the female age, which is related to a decline in the quantity and quality of eggs. Egg number decreases sharply when women age over 35 and the women close to menopause start having anovulatory cycles - normal menstrual cycles but without the release of an egg. 

As aging occurs, the possibility of an egg being genetically normal also decreases giving rise to an increased risk of miscarriages and failed to implant in the uterine wall. So, fertility evaluation is recommended for the couple who are trying to get pregnant for more than one year with above 40 female age.

- PCOS

PCOS is one of the most important causes of infertility in women. It affects every 1 in 10 women of the childbearing age. This is due to the imbalance of reproductive hormones, as a result of which women do not ovulate (release egg) as she does normally every month. Symptoms of PCOS include irregular menstrual cycle, excessive hair growth on the face, chin and other parts of the body, acne problems, thin hair, increase skin pigmentation, weight gain, etc.

- Fallopian Tubal blockage 

Fallopian tubes are a pair of narrow-lumen tubes that not only transport the egg from the ovary to the endometrial cavity but also are the site for fertilization of the egg. The blockage of one or both of the tubes due to an infection, disease, or trauma can decrease the chance of fruitful pregnancy.

- Uterine problems 

The uterus lodges the developing fetus during pregnancy. Uterine disorders such as fibroids, polyps, and endometrial scarring may be associated with irregular periods and reduced the chances of conception. Congenital uterine abnormalities are also one of the factors that contribute to infertility 

- Others

Cigarette smoking and alcohol consumption significantly reduces fertility both in men and women. Smoking during pregnancy increases the chances of miscarriage and birth defects.  

Medical conditions such as diabetes, epilepsy, and bowel diseases can also decrease the chance of getting pregnant.

Endocrine disorders such as hyperprolactinemia and thyroid diseases affect pregnancy.

Stress, overweight and eating disorders have a negative impact on fertility.

Male causes

Male contributes almost equally to infertility as female. The male causes of infertility include:

- Decreased sperm count

- Compromised sperm quality 

- Orchitis - inflammation of testicles that destroys the sperm-producing cells and result in decreased sperm count

- Undescended testes or testicular torsion can result in the total non-production of sperms.

- Certain occupations involving contact with chemicals or radiations are associated with male factor subfertility.

- Erectile dysfunction in the presence of normal production of sperms.

- Ejaculatory disorders

- Genetic factors such as Klinefelter syndrome XXY or structural abnormalities of autosomes such as deletions, inversion or translocation may also be the cause of infertility in males.  

Investigations

The inability to have a child gives rise to anxiety and stress among couples and a dire need to find out the root cause of their infertility. Both the partners need to be checked for possible conditions that are hindering in their wish to start a family. 

In females

A Transvaginal Ultrasound (TVUSS) is recommended for the accurate assessment of pelvic anatomy and to role out polyps, fibroids, adhesion, and other pathologies.

In females with a regular menstrual cycle, the following blood tests may be requested by the fertility specialist:

1. FSH levels in the early follicular phase of the menstrual cycle

2. Plasma levels of LH and estradiol.

3. Antimulerian hormones (AMH) levels are independent of the menstrual cycle and are helpful for the evaluation of ovarian reserve.

4. For the confirmation of ovulation, mid-luteal progesterone levels should be taken.

In women with an irregular menstrual cycle; thyroid profile, prolactin, and testosterone levels should be checked.

Antral follicle count is an important parameter for ovarian reserve. Follicle count has seen on 

In males

Semen fluid analysis is the only routine investigation in males. It is recommended to avoid intercourse before providing a semen sample for better results. If an initial result is abnormal it should be repeated after 3 months for adequate spermatogenesis. 

Total motile count 

Presence of round cells if there is a history of infection.

If the sperm count is low, you should go for hormone profile including FSH, LH, and testosterone level.

Sometimes karyotype and cystic fibrosis screens are also done.

Treatment

Ovulation induction

Patients with PCOS, ovulation induction is the first line of treatment. The agent used for this is clomiphene citrate. Clomiphene binds with estrogen receptors and blocks the release of normal estrogen through the feedback mechanism. As a result of this mechanism, there is a surge of gonadotropin release, stimulating the ovaries to form more and more follicles. 70% of women on clomiphene get pregnant.

If anovulation is intractable with clomiphene treatment, then induction is achieved with metformin, injectible gonadotropins, and aromatase inhibitors. 

GnRH analogs

Gonadotrophin releasing hormone (GnRH) is released from the hypothalamus - part of the brain - that acts on the pituitary to release FSH and LH which regulate the female menstrual cycle and reproductive period. GnRH analogs mimic the same action and are useful for the treatment of infertility due to menstrual irregularities, hypothalamic insufficiency, and when the ovulation induction with clomiphene has failed.  

Artificial reproductive technology (ARTs)

In cases of unexplained infertility and the failure of medical options, Artificial reproductive technology (ARTs) is a successful alternative to conventional treatment with success rate reaching up to 85% after 12 cycles of treatment.  

a. In vitro fertilization (IVF)

b. Intrauterine Insemination (IUI)

c. Intracytoplasmic sperm injection (ICSI)

All of these interventions can be performed in the fertility clinic as an outpatient procedure with or without the need for local anesthesia. 

Surgical Options

Some medical conditions require surgical intervention to eliminate infertility causes. The surgical treatment for infertility includes following procedures

- Ovarian drilling is done when PCOS is unresponsive to medical treatment. It is a surgical procedure in which electrical energy is passed through ovaries to induce ovulation. 

- Operative Laparoscopy: For polyps/adhesions, operative laparoscopy is used to treat this. It is also used in the case of ovarian cysts. 

- Laparoscopic ablation of endometriosis improves pregnancy rates.

- Myomectomy is recommended in cases of fibroid uterus, large polyps or Asherman’s Syndrome.