INFERTILITY

INTRODUCTION

The inability to have children affects couples and causes emotional and psychological distress in both men

and women. Despite the various social, psychological, economic and physical implications, infertility prevention and

care often remain neglected public health issues, or at least they rank low on the priority list, especially for low-

income countries that are already under population pressure. But in recent years there is increased awareness to

integrate infertility prevention, care and treatment into the basic health care services.

DEFINITION

Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical

pregnancy after 12 months or more of regular unprotected sexual intercourse (WHO-ICMART glossary*).

TYPES

There are two kinds of infertility –

primary and secondary:Primary infertility means that the couple has never conceived.

Secondary infertility means that the couple has experienced a pregnancy before and failed to conceive

later. Globally, most infertile couples suffer from primary infertility.

Symptoms
For a woman, infertility (or a state of subfertility) can manifest itself as either (WHO):

the inability to become pregnant

an inability to maintain a pregnancy

an inability to carry a pregnancy to a live birth.

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Causes
Infertility can be caused by both men and women factors. About a third of infertility problems are due to

female infertility and another third are due to male infertility. In remaining cases infertility may be due to

problems in both partners or the cause is unclear.

Female infertility can be caused by a number of factors:

(a)Damage to fallopian tubes: Damage to the fallopian tubes (carry the eggs from the ovaries to the

uterus) can prevent contact between the egg and sperm. Pelvic inflammatory diseases (PID) caused by

various infections, endometriosis, pelvic surgery may lead to damage to fallopian tubes. Sexually

transmitted infections (STIs) are the common cause of PIDs.

(b)Disturb ovarian function/hormonal causes: Synchronized hormonal changes occur during the

menstrual cycle leading to the release of an egg from the ovary (ovulation) and the thickening of the

endometrium (inner lining of the uterus) in preparation for the fertilized egg (embryo) to implant inside the

uterus. Difficulty in ovulation is seen in following conditions-

Polycystic ovary syndrome(PCOS) Polycystic ovary syndrome is the common cause of female infertility. PCOS

interferes with normal ovulation.

Functional hypothalamic amenorrhea: Excessive physical (common in athletes) or emotional stress may result in

amenorrhoea (absence of periods).

Diminished ovarian reserve or premature ovarian aging: women with diminished ovarian reserve may experience

difficulty in conceiving, (though blood test will show elevated follicular stimulating hormones).

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Premature ovarian insufficiency: Female ovaries stop working before she is 40 years of age. The cause can be

natural or it can be a disease, surgery, chemotherapy, or radiation.

(c)Uterine causes: Abnormal anatomy of the uterus; the presence of polyps and fibroids may lead to

infertility.

(d)Cervical causes: A small group of women may have a cervical condition in which the sperm cannot

pass through the cervical canal due to abnormal mucus production or a prior cervical surgical procedure.

Male factors causing infertility:

More than 90% of male infertility cases are due to low sperm counts, poor sperm quality, or both. The

remaining cases of male infertility can be caused by number of factors including anatomical problems,

hormonal imbalances, and genetic defects. Sperm abnormalities include:

Oligospermia (low sperm counts) /Azoospermia (no sperms): sperm count less than 20 million/ml is termed as

oligospermia whereas azoospermia refers to the complete absence of sperm cells in the ejaculate.

Asthenospermia (Poor sperm motility): If 60% or more sperms have abnormal motility (movement is slow and not

in straight line) it is termed as asthenospermia and may cause infertility.

Teratospermia (abnormal sperm morphology): about 60% of the sperms should be normal in size and shape for

adequate fertility.

Different factors including congenital birth defects, diseases (such as mumps), chemical exposure, and life

style habits can cause sperm abnormalities.

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Factors that affect the fertility of both sexes include the following:

Environmental/occupational factors

Toxic effects related to tobacco, marijuana, or other drugs

Excessive exercise

Inadequate diet associated with extreme weight loss or gain

Advanced age

Diagnosis
Both male and female factors can contribute to infertility. A detailed medical history, physical examination

and investigations are needed to assess the cause of infertility.

Evaluation of infertility includes following steps:

(a) History taking: Couples with infertility problem are interviewed separately as well as together to know

about important facts with full history taking. Full history includes: present history; menstrual and obstetric

history (in female partner); contraceptive and sexual history; family and past history.

(b)Clinical examination: Full clinical examination of both partners is required for detection of any physical

problem. It includes general examination along with examination of chest, breast, abdomen, and genitalia.

It helps to health care professional to make a provisional diagnosis. Investigations are advised to prove the

clinical diagnosis and to exclude other close possible causes.

(c) Investigations: Infertile couples are usually advised to start their investigations after 12 months of trying

to conceive or after six months if the female partner is more than 35 years old or immediately if there is an

obvious cause for their infertility or subfertility.

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As the major causes of infertility are sperm abnormalities, ovulation dysfunction, and fallopian tube

obstruction, the preliminary investigations for the infertile couple should be focused on:

Semen analysis: It should be done after 72 hours of sexual abstinence and two analysis should be

advised with 3 months apart at the same lab.(Results may be interpreted for its volume, sperm count,

motility, and morphology according to the WHO reference values*).

Female partner

Detection of ovarian function:

Hormonal assay (early follicular FSH and LH levels, and mid-luteal progesterone levels),

Transvaginal ultrasonography is used for detection of ovulation in females and any abnormality in uterus and

adnexa (adjoining anatomical parts of the uterus).

Evaluation of tubal patency:

Hysterosalpingography (HSG): It is a radiological procedure. The dye is injected in to the uterus through the cervix

and simultaneously X-Ray pictures are taken to see the movement of dye in to the fallopian tubes. Spilling of dye into

the abdominal cavity shows that tubes are patent.

Advanced investigations-

Hormonal assay: Thyroid function test, prolactin levels, testosterone, and other tests if polycystic ovary syndrome is

suspected.

Laparoscopy is a surgical procedure used to visualize abdominal and pelvic organs (uterus, fallopian tubes and

ovaries).

Hysteroscopy is indicated for intrauterine space-occupying lesions detected on HSG

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Chromosomal karyotyping is used for suspected genetic disorders.

Male partner-

Hormonal assay: FSH, LH, Testosterone, TSH and Prolactin (for male with abnormal seminal analysis and

suspected endocrine disorder)

Testicular biopsy: A fine-needle aspiration biopsy to differentiate between obstructive and non-obstructive

azoospermia.

Chromosomal karyotyping is used for suspected genetic disorders.

Management
Management of infertility ranges from counseling and advice to medications and surgery.

Counseling of both partners is an important aspect in the management of infertility with medical and

psychological support to the couple. Counseling is provided for the healthy life style measures such as:

Healthy eating habits-

Adding more whole-grain products, fruits, vegetables.

Limiting processed foods and foods with added sugars, eating a diet low in cholesterol and saturated fats

Promote regular exercise

No smoking (avoid passive smoking)

Limit alcohol intake

Maintain healthy weight

Folic acid supplementation in women

Advice on rubella vaccination if seronegative

Specific treatment of disease that causes infertility- Whatever cause is detected during investigations

relating to female or male partner, treatment is given accordingly.

When initial treatments don’t work, couple may decide for assisted reproduction technology.

Assisted reproduction techniques (ART):

Intrauterine insemination (IUI): IUI is the placement of a man’s sperm into a woman’s uterus using a long, narrow

tube. IUI may be used in the following conditions.

Defects of cervix

Low sperm counts

Sperm with low motility

Erection problems in male partner

Retrograde ejaculation (a condition in which sperms are deposited in to the bladder instead of going out through the

urethra)

Women who have scarring or defects of the cervix.

IUI is of two types

artificial insemination by husband (AIH);

donor insemination (DI).

In vitro fertilization (IVF): In vitro fertilization, eggs and sperm are taken from the couple and are incubated together

in a dish in a laboratory to produce an embryo. Medical specialist places the embryo into the woman’s uterus, where it

may implant and develop in a successful pregnancy.

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Gamete intrafallopian transfer (GIFT): in this procedure fertilization occurs naturally after eggs and sperm are

placed inside the fallopian tube.

Zygote intrafallopian transfer (ZIFT): In ZIFT fertilized eggs are transferred to fallopian tube within 24 hours after

fertilization.

Intracytoplasmic sperm injection (ICSI): In this procedure single sperm is injected in to mature egg. It is used to

treat sperm related infertility problems.

Surrogate and gestational carriers-If a woman is unable to carry a pregnancy to term, the couple may

choose a surrogate or gestational carrier.

A surrogate is a woman inseminated with sperm from the male partner of the couple. The resulting child will be

biologically related to the surrogate and to the male partner. Surrogacy can be used when the female of the couple

does not produce healthy eggs that can be fertilized.

A gestational carrier is implanted with an embryo that is not biologically related to her. This alternative can be used

when a female partner produces healthy eggs but is unable to carry a pregnancy to term. Egg or sperm donation can

be used in this situation.

Prevention
Adopting a healthier life style through simple lifestyle changes may help to reduce the chances of infertility.

Life style changes include:

(a)Weight management is important in preventing and treating infertility. Women who are overweight or

underweight ovulate less regularly compared to women of a healthy weight. Similarly overweight men are

likely to have reduced fertility. Therefore maintain a healthy weight with healthy diet and exercise.

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(b)Eat a balanced diet which should include whole grains, pulses, fresh fruits and vegetables, low fat milk

products. Limiting consumption of sugar, alcohol, caffeine, no smoking including passive smoking can have

a beneficial impact on a couple’s ability to conceive.

(c)Participating in moderate exercise can help improve menstrual regularities and overall health, whereas

sometimes excessive exercise can disturb menstrual cycle as seen in competitive athletes practicing

intense training sessions.

(d)Making time for leisure and enjoyment is a healthy step to lower stress levels and improves physical and

emotional health.

(e) Illegal drugs such as marijuana or cocaine should be avoided as can affect fertility.

(f) Practice safe sex-Sexually transmitted infections (STIs), such as chlamydia and gonorrhea, are leading

causes of infertility. STIs can lead to blockage of fallopian tubes, prostatitis and other problems that reduce

fertility.

(g)Age and fertility- The decision to have a baby and determining the right time to start a family is a highly

personal choice. However, women need to understand, that the biological clock is a real issue, older the

female partner, the more difficulty a couple can face when trying to get pregnant.

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