Infertility is an inability to get pregnant or to produce a baby after 1 year of unprotected sexual intercourse.
Altered fertility is another name for infertility.TYPES OF INFERTILITY
• Primary infertility
• Pregnancy has never occurred
• Secondary Infertility
• At least one previous pregnancy has occurred, but a successful pregnancy has not been realized at the current time.
• Relative Infertility or impaired fertility
• A set of conditions that may impede or postpone pregnancy but often can be corrected.
• Conception cannot occur and the causative factor cannot be reversed.CAUSES OF INFERTILITY
The cause may be present in either
• the man
• the woman
• or both of them.
FEMALE FERTILITY FACTORS
• Age: Fertility declines with age. Postponement of childbearing because of career can be a problem. If the woman has an existing disorder of the uterus like endometriosis, this will become worse with time and may lead to altered fertility.
• Ovulation problems: Ovulation failure may be due to problems in the hypo-thalamic-pituitary –ovarian axis or disorder of the thyroid or adrenal glands. These may lead to oligomenorrhea or amenorrhea due to decreased serum progesterone level.
• Previous Sexually Transmitted Diseases: Chlamydia or gonorrhea places the woman at risk of tubal damage or blockage or pelvic scaring, Past pelvic infection may result in scar tissue formation.
• Diseases processes: Thyroid disorders, diabetes, hypertension, cardiovascular diseases, kidney disorders, infections.
• Nutritional status: Body-fat ratio of less than 10% is considered malnutrition and this may result in anovulation, Obesity
• Athletes or anorexic women may have reduced pituitary hormones that may halt ovulation.
• Physical abnormality / anatomy of the reproductive organs e.g. retroflexed uterus
• Ovarian masses /cysts which may interfere with ovulation
• Problems with the uterine environment (endometrium): Endometritis, Endometriosis
• Recurrent ectopic pregnancies, Post operative inflammation of the tubal lumen.
• Chronic or excessive exposure to radioactive substances or x-ray.
• Uterine fibromas
• Cervical mucus problems
• Vaginal pH (acidic destroying the motility of the sperm.
MALE-FEMALE FERTILITY FACTOR
• Mucus –sperm incompatibility
• Sperm immobilizing or sperm-agglutinating antibodies in their blood plasma that act to destroy sperm in the vagina or cervix.
MALE FERTILITY FACTORS
• Sterility after infections like gonorrhea or tuberculosis, causing blockage in the vas deferens.
• Exposure to environmental toxins like pesticide, herbicides may affect the quality or quantity of sperm
• Exposure to radioactive substances or x-ray.
• Drug or alcohol abuse .
• Problems related to sperm production or motility (movement)
• Constant use of hot tubs
• Too tight fitting underwear and pants
• Physical abnormalities of the genitals e.g. cryptorchidism (undescended testes), testicular atrophy as a result of post pubescent mumps
• Varicose veins in the scrotum increases the temperature within the testes.
• Surgery on or near the testicles that result in impaired testicular circulation or previous herniorrhaphy resulting in scar tissue formation
• Previous vasectomy for sterilization
• Impotence (inability for the male to achieve or maintain erection
• Pre-mature ejaculation
• Psychological factors like job & financial stress, fatigue, depression, anxiety surrounding sexual intercourse, illness.
• Trauma to the testes
• Hypertrophy of the prostrate gland
Investigations – Female
• Evaluation of ovulation
• Basal body temperature
• Cervical mucus method
• Hormonal assessment
a) FSH and LH levels
b) Progesterone assays: 5 ng/mL on 3rd day and
10 ng/mL on 21st day (7th day postovulation).
e) Androgen levels
Basal body temperature (BBT)
Fern pattern of cervical mucus
Investigations – Female
• Endometrial biopsy: Done 10-12 days after ovulation
• Transvaginal ultrasound (TVS)
• Postcoital test (Huhner test): Done 1 or 2 days before ovulation. Cervical mucus is aspirated 2- 8 hours after unprotected intercourse.
• Tubal factors
• Hysterosalpingography (HSG): X-ray visualization of the uterus, fallopian tubes and peritoneal cavity after injection of a radio opaque dye. Should be done on the 5th – 10th days of menstrual cycle.
Investigations – Male
• Semen analysis: Semen is collected by masturbation. Better results if done after 2-3 days of abstinence. Do not use ordinary condoms for specimen collection.
• Normal Findings
• Volume – more than 2 mL
• pH- 7-8
• T. sperm count- more than 20 million/mL
• Liquefaction- Complete in 1 hr
• Motility- 50% or more
• Morphology- 30% or more normal
This will depend on the cause of the problem.
Problems in the Female
• Ovulation failure: This can be treated with dopamine receptor agonist which lowers prolactin levels allowing resumption of ovulation e.g. bromocriptine.
• Clomid (Clomiphene citrate) is a common drug of choice for women with decreased serum progesterone level, this drug enhances follicular development and induces ovulation.
• For Uterine problems: Congenital anomalies, fibroid etc, surgical correction or removal.
• For tubal problems: Correction of tubal blockage, and some may be difficult to correct.
• In this situation several techniques of Assisted Reproductive Technology.
• IVF (In Vitro Fertilization): Mature eggs are harvested by laparoscopy or needle aspiration and fertilized in vitro with washed sperm. When the oocytes reaches the four to eight cell stage, they are transferred to the uterus.
• ICSI (Intra cytoplasmic sperm injection): sperm is injected directly under the zona pellucida of the mature ova to fertilize it.
• Cervical mucus problem: Medications are available to restore normal mucus producing patterns.
Male- Female Factor
Cervical mucus problem/ mucus –sperm incompatibility:
• Intra-uterine insemination, a type of artificial insemination by injecting the concentrated sperm directly into the uterine cavity by means of a slender flexible plastic catheter.
Problems in the Male
• Reduce Sperm Count or Motility
* Reduction of heat to the scrotum.
* Hormonal treatment with Clomid to increase sperm count.
* Artificial Insemination with husband sperm
* Here the sperm is directly delivered to the cervix by means of a cup device similar to a cervical cap, which allows the cervix to rest in the seminal pool.
• Psychological factors
* Counseling and referral to support groups where available can be very helpful.