What is Infertility?

Reproductive endocrinologists, the doctors specializing in infertility, consider a couple to be infertile if:

  • The couple has not conceived after 12 months of contraceptive-free intercourse if the female is under the age of 34 yrs.
  • This interval may be decreased to 6 months if the woman's age is more than 34yrs (It's better to seek medical help earlier due to declining egg quality in older women.)

In women, this may be due to blockage in the Fallopian tubes, failure of ovulation, a deficiency in sex hormones, or general ill health.

In men, impotence, an insufficient number of sperm or abnormal sperm may be the cause of infertility.

Clinical investigation will reveal the cause of the infertility in about 75% of couples and assisted conception may then be appropriate.

What is Subfertility?

Sub fertility is a decreased capacity to conceive, including miscarriage. The important distinction between infertility and sub fertility is that it may take considerably longer for sub fertile couples to conceive but there is still a possibility that they can.

What is the difference between Primary & secondary infertility?

Couples with primary infertility have never been able to conceive. While, on the other hand, secondary infertility is difficulty conceiving after already having conceived (and either carried the pregnancy to term, or had a miscarriage). Technically, secondary infertility is not present if there has been a change of partners.

How common is Infertility?

Generally, worldwide it is estimated that one in seven couples have problems conceiving, with the incidence similar in most countries independent of the level of the country's development.

Usually around 80% of the couple who have regular intercourse (at least twice a week) conceive within a year. Similarly around 90% of the couple conceive within 2 yrs of unprotected intercourse. Women become less fertile as they get older. The effect of age upon men's fertility is less clear.

Isn't infertility is a stressful problem to deal with?

Yes. Infertility may have profound psychological effects. Partners may become more anxious to conceive, ironically increasing sexual dysfunction. Marital discord often develops in infertile couples, especially when they are under pressure to make medical decisions. The couples undertaking IVF face considerable stress . Proper understanding of the reason for infertility and further course of treatment along with sensitive counseling helps to reduce the stress considerably.

What are the causes of infertility in women?

For a woman to conceive, certain things have to happen:

  • Intercourse must take place around the time when an egg is released from her ovary
  • The systems that produce eggs have to be working at optimum levels
  • Her hormones must be balanced.
  • Endometriosis or damage to the fallopian tubes (which may have been caused by infections such as chlamydia).
  • Being over or underweight for her age.

Female fertility declines sharply after the age of 35. Sometimes it can be a combination of factors, and sometimes a clear cause is never established when it is termed unexplained infertility.

How does age affect a woman's ability to have children?

More and more women are waiting until their 30s and 40s to have children. Age is an increasingly common cause of fertility problems. About one third of couples in which the woman is over 35 have fertility problems.

Aging decreases a woman's chances of having a baby in the following ways:

  • The ability of a woman's ovaries to release eggs ready for fertilization declines with age.
  • The quality of a woman's eggs declines with age.
  • As a woman ages she is more likely to have health problems that can interfere with fertility.
  • As a women ages, her risk of having a miscarriage increases.
What causes infertility in men?

Infertility in men is most often caused by:

  • Problems making sperm : producing too few sperm or none at all
  • Problems with the sperm's ability to reach the egg and fertilize it : abnormal sperm shape or structure or immunological problems prevent it from moving correctly
  • Sexual Dysfunction : Men with major problems of erection / ejaculation are unable deposit the sperms in the vagina.
Are there any other causes?

Other uncommon factors that can cause male as well as female infertility are:

  • Genetic Factors : A Robertsonian translocation in either partner may cause recurrent spontaneous abortions or complete infertility.
  • General factors : Diabetes mellitus, thyroid disorders, adrenal disease
  • Hormonal disturbances Kallmann syndrome, Hyperprolactinemia, Hypopituitarism
  • Environmental Factors : Toxins such as glues, volatile organic solvents or silicones, physical agents, chemical dusts, and pesticides.
What is combined infertility?

In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the combination of these conditions. It may be that each partner is independently fertile but the couple cannot conceive together without assistance.

What is unexplained infertility?

In about 10-20% of cases the infertility investigations will show no abnormalities. In these cases abnormalities are likely to be present but not detected by current methods.

Possible problems could be that the egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails.

It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.

When should I see the doctor?

Though the women under 35 can wait till one year before going for any evaluation, it's a wise idea to see your doctor before trying to conceive as your health can be optimized before conceiving.

This includes pre conceptional Folic acid intake, weight management, reverting to healthy life style etc.

Some health issues also increase the risk of fertility problems. So women with the following issues should speak to their doctors as soon as possible:

  • irregular periods or no menstrual periods
  • very painful periods
  • endometriosis
  • pelvic inflammatory disease
  • more than one miscarriage
What's involved during the first visit?

During the first visit your doctor will take a detailed medical history and give a physical examination. There will be a counseling session with the nurse where an outline of fertile period, the process of conception is given.

The evaluation of the male's medical history includes a discussion of previous pregnancies, developmental problems, surgeries, testicular trauma or infections and environmental exposure.

What are the tests usually done?

The tests usually include

  • Basic blood tests for both the partners
  • Hormonal tests if required
  • HSG - Hysterosalpingogram, for the woman -It's a type of X Ray to see if the Uterine cavity is normal and to check whether the Fallopian tubes are patent.
  • Trans Vaginal Scan (TVS) for the woman - Is an internal pelvic scan to check the pelvic organs including uterus and Ovaries.
  • Semen Analysis for the man - to check the sperm count, motility and normal forms
  • Additional tests / laparoscopy may be advised depending on the information gained by the above tests.
  • Thyroid - an underactive thyroid can result in high prolactin levels interfering with pregnancy.
How are hormone tests interpreted?

Hormonal studies measure the levels of certain hormones produced by your body during each menstrual cycle. Hormones affect every step necessary in achieving pregnancy from stimulating the development of an egg to ovulation and implantation of a fertilized egg in the uterus. If the hormones that affect fertility are not produced in specific amounts at specific times during your cycle, your chances of conceiving a child may be greatly inhibited.

Your physician may run tests to determine the levels of the following hormones that play a role in ovulation and implantation of the egg:

  • Estradiol - stimulates the growth of the follicles and the production of cervical mucus from the cervix, and prepares the uterine lining for implantation of a fertilized egg
  • Follicle stimulating hormone (FSH) - stimulates the development of the egg
  • Luteinizing hormone (LH) - stimulates the release of the egg from the follicles
  • Progesterone - stabilizes the uterine lining for implantation of a fertilized egg and supports early pregnancy The overproduction of the following hormones can negatively affect ovulation:
  • Androgens - normally small amounts of androgens (testosterone) are produced in women; excess production can interfere with development of the follicles, ovulation and cervical mucus production
  • Prolactin - stimulates milk production; prolactin levels may be higher than normal in certain disorders or when certain medications are taken
  • Thyroid - an underactive thyroid can result in high prolactin levels
What is HSG?

A hysterosalpingogram (HSG) is an X-ray of the uterus and fallopian tubes which allows visualization of the inside of the uterus and tubes. The picture will reveal any abnormalities of the uterus as well as tubal problems such as blockage and dilation (hydrosalpinx). If sterilization reversal is planned, the point at which the tubes are blocked can be seen. This helps to plan the reconstructive procedure.

If the tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally. It does give a rough estimate of the quality of the tubal structure and the status of the tubal lining. Some cases where the tubes appear to be blocked where they join the uterus, may in fact be normal. Often blockage at this location may be due to spasm of the opening from the uterus into the tube or from accumulated debris and mucus blocking the opening. This can be managed by passing a very thin catheter into the fallopian tube either at the time of hysterosalpingogram or during a hysteroscopic procedure.

A hysterosalpingogram may also indicate endometrial polyps, submucus fibroids, intrauterine adhesions (synechia), uterine and vaginal septa uterine cavity abnormalities, or the after-effect of genital tuberculosis. The hysterosalpingogram may or may not be able to detect pelvic adhesions, mild hydrosalpinx, small polyps, endometriosis, tubal phimosis (clubbing of the fimbria at the end of the tube), or immotility of the tube. Other tests, such as hysteroscopy saline sonohysterography or laparoscopy may be necessary to accurately evaluate your uterus.

Although the purpose of the hysterosalpingogram is not therapeutic, sometimes forcing dye through the tube will dislodge any material which blocks it. A number of women have become pregnant following a hysterosalpingogram without further treatment.

Generally there is no special preparation needed for this test. However, depending upon your diagnosis, you may need to take antibiotics to guard against possible infection. To ensure that you are not pregnant, the study is done between Day 7 and 10 of your cycle. Prior to the procedure you may take an anti-inflammatory medication. A small catheter is placed into the cervix and the dye is injected. You may feel heavy cramping during, and for several hours following this procedure. Expect a sticky vaginal discharge for a few days as the dye is expelled from the uterus. Use a pad or panty liner during this time to allow fluid to escape. Any dye that remains will be absorbed without any ill effect.

NOTE: Be sure to inform the doctor of any allergies you may have to Iodine, Betadine, or Novocaine prior to the procedure.

If cramping does not subside or if you develop severe abdominal pain or fever following this test, please notify or report to Santasa Hassan.

What is Laparoscopy?

Laparoscopy is an innovative surgical procedure performed through very small incisions in the abdomen using pencil-thin instrument called a laparoscope which gives the surgeon an exceptionally clear view of the abdominal cavity on a TV monitor.

What does semen analysis involve?

When male factor infertility is suspected, the initial test performed is a semen analysis.

  • Sperm count : The normal range for sperm is between 40 and 300 million sperm per milliliter of ejaculate. A low sperm count is fewer than 20 million per milliliter of ejaculate.
  • Motility : Low sperm motility (movement) may reduce the chances of conception, especially when paired with low sperm count. In a normal semen sample, at least half of the sperm have typical movement.
  • Morphology : Sperm that do not have normal morphology (shape) are often unable to swim effectively or penetrate an egg. A normal sperm has an oval head, slender midsection and tail that move in a wave-like motion.

In order for a physician to evaluate the count, motility and morphology of sperm, a semen sample must be provided. The sample is most often collected by masturbation in a private, comfortable room in the fertility center. In some cases, the sample may be collected at home by masturbation or during intercourse with the use of a special condom provided by the physician. In some cases, the test results are not normal due to problems during sample collection and the test must be repeated. Depending on the results of the semen analysis, more tests can be ordered to diagnose specific causes of infertility. If the semen analysis shows clumping or signs of infection, a semen culture, prostate fluid culture and urinalysis may be ordered. An antisperm antibody test may also be ordered to evaluate potential immune system disorders. A fructose test can be used to evaluate structural problem or a blockage of the seminal vesicles.

How do doctors treat infertility?

Many of the couple may benefit with knowledge about fertile period or just ovulation tracking and timed intercourse.

Infertility can be treated with medicine, surgery, artificial insemination or assisted reproductive technology. Many times these treatments are combined.

About two-thirds of couples who are treated for infertility are able to have a baby.

Doctors recommend specific treatments for infertility based on:

  • Test results
  • How long the couple has been trying to get pregnant
  • The age of both the man and woman
  • The overall health of the partners
  • Preference of the partners

Various fertility medicines are often used to treat women with ovulation problems. It is important to talk with your doctor about the pros and cons of these medicines. You should understand the risks, benefits, and side effects.

Doctors also use surgery to treat some causes of infertility. Problems with a woman's ovaries, fallopian tubes, or uterus can sometimes be corrected with surgery.

Doctors often treat infertility in men in the following ways:

Sexual problems: If the man is impotent or has problems with premature ejaculation, doctors can help him address these issues. Behavioral therapy/counseling and/or medicines can be used in these cases.

Too few sperm: If the man produces too few sperm, sometimes medicines can improve this problem. In other cases, doctors can surgically remove sperm from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.

The men with poor sperms can be helped with methods like IUI or ICSI.

What is Ovulation Induction?

Ovulation induction is a type of medical therapy often performed alongside certain fertility treatments. Typically, medications that are used to help trigger the development of egg follicles are known as ovulation inducers. Ovulation induction often triggers the development of more than one egg during ovulation.

Why Induce Ovulation?

Ovulation is often induced in order to help women who cannot ovulate regularly produce an egg during their monthly cycle. Ovulation induction is also used in order to trigger the ovaries to release more than one egg during ovulation. Sometimes, inducing ovulation can allow two or three eggs to be released at once, therefore increasing your chances of pregnancy.

Who Can Benefit from Ovulation Induction?

A large percentage of women seeking fertility treatment can benefit from ovulation induction. In particular, women suffering from the following conditions may find ovulation induction particularly helpful in increasing their chances of pregnancy:

  • Anovulation
  • PCOS (Polycystic Ovarian Syndrome)
  • Pituitary disorders
  • Irregular menstruation (oligomenorrhea)
What are the factors Affecting Ovulation Induction?

There are certain factors that will affect the success of ovulation. Before choosing ovulation induction, your reproductive endocrinologist will evaluate:

  • your egg quality
  • your egg quantity

If the quality and quantity of your ovarian reserve is poor, ovulation induction may not be the right route for you.

Types of Ovulation Inducers

1. Clomid

Clomid, or clomiphene citrate, is one of the most well known ovulation inducers. Clomid is a relatively inexpensive fertility medication and can usually be used with limited monitoring. However, it does require some blood testing, so it should only be used with the supervision of your reproductive endocrinologist.

How Is Clomid Taken?

Clomid is taken orally, on specific days of your menstrual cycle. It is typically on through Days 3 to 7 or through Days 5 to 9. It is sometimes paired with Provera, a medication that can help to induce menstruation. The initial dose of Clomid is taken immediately after your menstrual period begins. This dose is typically around 50 milligrams, although it can be increased if ovulation does not occur.

After Ovulation Begins

Your reproductive endocrinologist will monitor you for ovulation. When an egg is released, you and your partner will engage in timed intercourse, in order to increase the chances of conception. Fertility treatments, including IUI will also begin at this time.

Clomid Success Rates

Clomid is usually highly successful in inducing ovulation. Between 50% and 80% of women taking Clomid will begin to ovulate. However, this does not necessarily mean that you will be able to achieve pregnancy. Pregnancy rates per cycle are typically between 10% and 15%, however this depends upon the type of fertility treatment that you and your partner are using. Pregnancy rates with Clomid are lower because the medication can sometimes compromise the quality of your eggs and cervical mucus.

2. Injectable Gonadotropins

Injectable gonadotropins are also used to help induce ovulation in certain women. This medication works to induce ovulation as it contains FSH(follicle stimulating hormones). FSH helps to trigger the development of follicles inside of your ovaries, triggering ovulation. This type of fertility medication is more expensive then Clomid. As many as six ampules of the medication may be required for every injection day.

How are Gonadotropins Taken?

Gonadotropins are also taken on specific days of your menstrual cycle. Intramuscular injections containing the gonadotropins are usually adminstered by your care giver for a period of eight to 14 days. As your follicles begin to show signs of maturation, you will also receive an injection of hCG(Human chorionic gonadotrophin (hCG) a glycoprotein hormone), to help induce ovulation.

After Ovulation Begins

After ovulation begins, you and your partner will be instructed to have timed intercourse, or to make an appointment to begin IUI treatments.

Gonadotropin Success Rates

Gonadotropin is highly successful when it comes to inducing ovulation. More than 70% of women taking this drug begin to ovulate. Pregnancy rates per cycle are generally around10 - 15% . However, gonadotropin is not without its side effects. There is a risk of multiple births when using gonadotropins to stimulate ovulation. Approximately 15% of all pregnancies are twins, and 3% are triplets or higher order multiples. There is also a risk for developing hyperstimulation, in which your ovaries become enlarged, and your abdominal area becomes swollen with fluid. This can be avoided with proper monitoring.

3. Metformin :

Doctors use this medicine for women who have insulin resistance and/or Polycystic Ovarian Syndrome (PCOS). This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.

4. Bromocriptine Cabergoline

These medicines are used for women with ovulation problems due to high levels of prolactin . Prolactin is a hormone that causes milk production which also suppresses ovulation.

They are highly effective at restoring normal ovulation and menstruation. More than 90% of women using bromocriptine/cabergoline, experience normal menstrual cycles. They are not associated with an increased risk for multiple births or with ovarian hyperstimulation.

IUI - How it's done?

Depending on your particular fertility problem you may or may not be advised to use fertility drugs alongside the IUI treatment. If fertility drugs are used it is called a "stimulated cycle" because the drugs stimulate ovulation. If drugs are not used it is called an "unstimulated cycle" or "natural cycle".

Stimulating ovulation is not recommended alongside IUI if it's only your partner that has the fertility problem, or if the reason for infertility is unexplained. This is because there is a much greater risk of a multiple pregnancy in these cases.

While many couples with fertility problems think that twins or more would be a great way to start a family, the reality is that multiple pregnancies increase your risk of miscarriage and other pregnancy complications.

In unstimulated cycles, IUI is timed to take place at the time of natural ovulation. You may be asked to detect ovulation using an ovulation predictor kit, or your doctor may track your cycle using blood and urine tests. IUI is usually done between about day 12 and day 15 of a natural menstrual cycle, but the exact day will depend on your particular cycle and when ovulation is detected.

If your fertility specialist has offered you IUI during a stimulated cycle, you'll probably be given fertility drugs in the form of an injection and nasal spray. You'll start taking the drug near the beginning of your menstrual cycle to stimulate your ovaries to develop several mature eggs for fertilisation. (You normally release only one egg a month.) Your doctor will use ultrasound to detect ovulation and make sure that insemination is carried out at the optimum time. You may ovulate naturally, or be given an injection of the hormone hCG (human chorionic gonadotrophin) to bring this on.

Once you ovulate, your partner produces a sperm sample, which is "washed" to extract the best quality, most mobile sperm. Using a catheter (tube) through your cervix, doctors then put this sperm directly into your uterus near a fallopian tube (the passage the egg travels along from an ovary to your uterus). This is IUI.

If you have unexplained infertility, the sperm may be inserted within a larger volume of fluid than usual so it can wash up into the fallopian tubes more easily. This technique takes a few minutes more than standard IUI and is known as "fallopian sperm perfusion". It has been shown to increase the chances of success in cases of unexplained fertility.

You rest for a short time afterwards and then carry on life as normal. You'll be able to take a pregnancy test in about two weeks.

How successful is an IUI?

Success rates depend on the causes of you and your partner's infertility and your age. The success rate for IUI with fertility drugs is about 15 percent per cycle.

What happens during laparoscopy?

Laparoscopy is usually performed under general anesthesia; however it can be performed with other types of anaesthesia that permit the patient to remain awake.

The typical pelvic laparoscopy involves a small (1/2" to 3/4") incision in the belly button or lower abdomen. The abdominal cavity is filled with carbon dioxide. Carbon dioxide causes the abdomen to swell which lifts the abdominal wall away from the internal organs, so the doctor has more room to work.

Next, a laparoscope (a one-half inch fiber-optic rod with a light source and video camera) is inserted through the belly button. The video camera permits the surgeon to see inside the abdominal area on video monitors located in the operating room.

Depending on the reason for the laparoscopy, the physician may perform surgery through the laparoscope by inserting various instruments into the laparoscope while using the video monitor as a guide. The video camera also allows the surgeon to take pictures of any problem areas he discovers.

Risk associated with laparoscopy

Risks for any type of surgery may be greater for people who are obese, smoke cigarettes, or have additional health problems like Diabetes or Hypertension.

Recovery period following laparoscopy

Laparoscopy results in relatively little pain and a quick recovery for most patients. Patients sometimes experience aches in the shoulders or chest following laparoscopy. This is because of the carbon dioxide that was used to fill the abdominal cavity. Most of the patients are fit to get discharged within a day or two.They can usually resume their daily activities within next few days.

What happens during Hysteroscopy?

Diagnostic Hysteroscopy is an out patient procedure which can be done either in the OPD(Office Hysteroscopy) or in the OT.

Operative Hysteroscopy is a major surgical procedure and involves usually General anaesthaesia. The distending media used are normal saline, Carbon Dioxide or Glycine.

The various problems like Endometrial Polyps or submucosal fibroids can be addressed with Hystroscopic surgery.

What happens if I have too much testosterone?

High levels of testosterone cause some symptoms of PCOS. You may have more body hair than most women. In addition, you may be overweight. Your periods may be irregular. Your ovaries may not release eggs every month, so you probably don't ovulate regularly and you may have a difficult time becoming pregnant.

What is ovarian drilling?

In patients with PCOS, your ovaries typically have a thick outer surface and you may produce more testosterone than women without PCOS. Ovarian drilling breaks through the thick outer surface and the drilling also reduces the amount of testosterone your ovaries make. In this laparoscopic (minimally invasive) procedure, a tiny camera attached to a thin telescope is inserted into a small incision (surgical opening) below your belly button. Special tools are inserted at other on your belly. These tools make very small holes in your ovaries, which help reduce testosterone production. You may get your period regularly and you should start to ovulate.

Will I get pregnant after ovarian drilling?

Your chances of pregnancy are good as long as your menstrual cycles become more regular and no other problems make it hard for you to conceive. In the year after ovarian drilling, about half of the patients get pregnant. You are less likely to get pregnant with twins or triplets after ovarian drilling than if you are taking fertility drugs. However, your cycles may become irregular again as time goes by. Sometimes menstrual cycles do not become more regular after this surgery, but it may be easier to induce ovulation with fertility drugs after the surgery.

What are the risks of ovarian drilling?

This surgery could cause injury to your intestines, bladder, blood vessels, and ureter. You could also have bleeding, an infection, or a reaction to anesthesia. There is a risk of death, but it is rare. If there is too much damage to the ovary, you may run out of eggs at a younger age and go through menopause (which is when you stop getting your period). After the surgery, adhesions or scar tissue can form between the ovaries and the fallopian tube, which carries the egg out of the ovary into the uterus. If you develop adhesions, it may be more difficult for you to get pregnant.

  • Dr. Sowmya Dinesh H R

    MBBS, MS, FRCOG (U.K) Reproductive Medicine Fellowship, S'Pore Chief Fertility Specialist & Gyn. Endoscopic

  • Dr. Yogitha Sanjay

    MBBS, DGO, PGA (U.K) Msc-clinical embryology & PGD Chief Embryologist and Fertility Specialist

  • Dr. Savithri. A.

    MBBS, MD Consultant Obstetrician and Gynaecologist, malnad nursing home, Hassan

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