Most people have a strong desire to conceive a child at some point during their lifetime. Understanding what defines normal fertility is crucial to helping a person, or couple, know when it is time to seek help. Most couples (approximately 85%) will achieve pregnancy within one year of trying, with the greatest likelihood of conception occurring during the earlier months.
Infertility is often defined as not conceiving after 12 months of regular sexual intercourse without the use of birth control. Worldwide, up to 15 % percent of couples experience fertility problems. This inability to conceive is becoming an increasingly common problem with an estimated incidence of almost 3.9% – 16.8 % in India.
Pregnancy is the result of a process that has many steps.
To get pregnant
- A woman’s body must release an egg from one of her ovaries (ovulation).
- A man’s sperm must join with the egg along the way (fertilize).
- The fertilized egg must go through a fallopian tube toward the uterus (womb).
- The fertilized egg must attach to the inside of the uterus (implantation).
Infertility may result from a problem with any or several of these steps.
The major causes of infertility can be divided into conditions causing problems in female partner, conditions affecting the male partner, and some cases where no cause is identified labeled as unexplained infertility.
Infertility in women
Conditions affecting a woman’s fertility can include:
- Damage to the fallopian tubes
- Ovulatory problems- polycystic ovary syndrome (PCOS)
- Conditions affecting the uterus like fibroids
- A combination of factors
- No identifiable reason.
- Age – female fertility declines sharply after the age of 35
- Gynecological problems such as previous ectopic pregnancy or having had more than one miscarriage
- Medical conditions such as diabetes, epilepsy, and thyroid and bowel diseases
- Lifestyle factors such as stress, being overweight or underweight, and smoking.
Infertility in men
Conditions that may result in infertility include:
- low sperm count or quality
- problems with the tubes carrying sperm
- problems getting an erection
- Problems ejaculating.
- having had inflamed testes (orchitis)
- a past bacterial infection that caused scarring and blocked tubes within the epididymis as it joins the vas
- having received medical treatment such as drug treatment, radiotherapy or surgery – for example to correct a hernia, undescended testes or twisted testicles
- genetic problems
- Lifestyle factors such as being overweight or having a job that involves contact with chemicals or radiation.
Male fertility is also thought to decline with age, although to what extent is unclear.
The initial workup for an infertile couple is done to select the right kind of fertility treatment for such couples based on the reports. The infertile couples must undergo a set of advanced tests before the commencement of any treatment. These tests are comprehensive & detailed and are essential to determine the causes of infertility, whether the couples are diagnosed with any other ailment and which technique would be most suitable for a particular couple.
Female partner must undergo a trans-vaginal ultrasound to evaluate ovarian reserve & uterus condition, blood tests, and laparoscopy or hysteroscopy in cases where there is an indication of such operation requirement after the initial workup.
Male partners need to undergo a semen analysis to determine the quality, quantity, and motility of the sperm along with few blood tests.
A variety of procedures can be used to diagnose the cause of infertility in a couple, these range from simple blood tests to more complicated analytical methods. In any case, diagnosis is a crucial first step to determine the appropriate therapeutic path that should be followed. In addition to the cause itself, other factors, such as the age of the woman, or problems shared by both partners, might also influence the choice of treatment.
Several options are offered to couples depending on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as Clomiphene Citrate, Bromocriptine or Gonadotrophins. Surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Treatment options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies, such as Intracytoplasmic Sperm Injection (ICSI). Drug therapy and surgery have proved very successful for specific types of male infertility. However, in a large number of cases, the reason why men have fertility problems remains unexplained and the treatment methods applied are empirical. Some patients nevertheless require more complex medical intervention.
Assisted reproductive technologies (ART) refer to several different methods designed to overcome barriers to natural fertilization such as anatomical problems (e.g. blocked fallopian tubes). One of these techniques, in-vitro fertilization (IVF), has now been practiced for more than 15 years.
When talking of success rates for any type of infertility treatment, one should bear in mind that the average chance to conceive for a normally fertile couple having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may, therefore, need to be repeated several times before a pregnancy is achieved.
In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple’s infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).
Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensure successful treatment.
Monitoring techniques (such as ultrasound scan and blood tests) and appropriate use of treatment protocols help to avoid ovarian hyperstimulation syndrome (OHSS) and minimize the risk of multiple pregnancies.
Ovarian Hyperstimulation Syndrome (OHSS) can occur during infertility treatment with ovulation-inducing drugs. Symptoms of this syndrome may include ovarian enlargement, accumulation of fluid in the abdomen and gastrointestinal disorders (nausea, vomiting, diarrhea). Severe cases of OHSS are however very rare (1-2% of cases). One may have to admit the patient in an Intensive Care Unit. Rarely, she may need to undergo abdominal tap procedure, to remove fluid from her abdomen. Very rarely, she may need more intensive therapies such as dialysis, or respirator. In order to prevent or reduce the severity of OHSS, intravenous albumin may be given at the time of egg pickup during IVF/ICSI procedure.
Multiple births occur more frequently after infertility treatment than in the normal population. About 80% of pregnancies achieved following simple ovulation induction result in single births, the remaining 20% being multiple pregnancies, mostly twin pregnancies. New treatment regimens carefully adapted to the patient’s response help to decrease the risk of multiple pregnancies.
After IVF, one pregnancy out of four is multiple. Infertility centers, physicians now frequently choose to replace a maximum of three embryos after fertilization, to further reduce the chance of multiple births. Alternatively, many units are going in for blastocyst culture, especially if there are 3 or more 8 cell embryos available for transfer on day 3.
In the case of triplets or more, one can offer the procedure of Fetal Reduction, to the patient. In this, with the help of sonography, a thin needle is passed into the fetus, and drugs are injected to stop the fetal heart. Care is taken to see that at least two intact fetuses are left behind. This is a relatively simple technique, with minimal side effects. However, some patients may avoid this technique for religious or personal reasons.
Common local side effects experienced by patients who receive gonadotrophins by intramuscular injection include skin redness, swelling and bruising. Pain and discomfort sometimes reported after intramuscular injections are now likely to be lessened with the availability of a highly purified follicle stimulating hormone preparation which can be administered subcutaneously. Nowadays drugs produced by recombinant DNA (or genetic engineering techniques) are available for administration by subcutaneous injection.
Ovarian cancer is a rare disease; the chance of a young woman developing an ovarian malignancy during her lifetime is lower than 1.5%. A number of factors have been found to increase the risk of ovarian cancer, including genetic predisposition and dietary habits. Scientific studies carried out in the last few decades have demonstrated that infertility itself is a risk factor for ovarian cancer.
There is evidence that each pregnancy reduces the risk of a woman contracting ovarian cancer (this risk could be reduced by more than 25% by a first pregnancy). No epidemiological study has ever established a causal link between ovulation promoting drugs and ovarian cancer. An extensive study on this issue, reporting on more than 2,600 women treated between 1964 and 1974 and followed for an average of twelve years, found no association between ovulation inducing drugs and ovarian cancer.
Regarding children born following treatment with ovulation promoting drugs, the incidence of birth defects is the same as that in the normal population. The same goes for babies conceived after IVF. The incidence of malformations is around 2%, which is comparable to that of babies born naturally, without anytreatment.
The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but before a treatment is started, patients need to be aware of all its aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support. From a psychological point of view, infertility is often a hard condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be exacerbated. Management of infertility includes both the physical and emotional care of the couple. Therefore, support from physicians, nurses and all people involved in treating the infertile couple is essential to help them cope with the various aspects of their condition. Offering counseling and contact with other infertile couples and patient associations can provide help outside the medical environment.
To increase the chance on getting pregnant spontaneously, timed sexual intercourse is recommended. This means that sexual intercourse, or coitus, has to take place around the time of ovulation, which is the most fertile period of a woman.
One can use a serial ultrasound monitoring to follow the development of the follicle and subsequent rupture which indicates ovulation. The time of ovulation can sometimes vary a few days each month, even in a regular menstrual cycle. Also, if the circumstances are right, sperm can live inside the women for a few days and sperm quality can decrease with high sexual activity. Therefore, it is best to have intercourse 3-4 days before the expected ovulation and every other day until 2-3 days after the expected ovulation with no necessity for higher frequency.
Assisted Reproductive Therapy (ART) has caused an increase in multiple pregnancies. Especially in Ovulation Induction and Intra Uterine Insemination, this situation is encountered frequently. In order to prevent the risk of severe premature birth and handicaps as well as risks for the mother, embryo reduction is sometimes performed: The number of embryos in the uterus are reduced and the remaining pregnancy has more chance of normal development and delivery. Of course, this is not an easy decision for both patient and doctor. With careful guidance of the patient during treatment and good counseling when the patient is at risk for large multiple pregnancies, many triplets or higher pregnancies are already avoided.
One complete IVF or ICSI cycle takes approximately six to eight weeks. First, the normal menstruation cycle of the woman is down-regulated by injection or nasal application of specific hormones each day. This part of the cycle can vary from a few days to several weeks. When the ovaries have become inactive, as shown on ultrasound control and laboratory findings, the stimulation of the ovaries starts by intramuscular or subcutaneous injections of hormones. The mean stimulation period is 12 days, depending on the reaction of the ovaries. The ovum pick up takes place within two days after stopping the stimulation. Now the IVF or ICSI follows in the laboratory. When fertilization occurs, embryos are transferred into the uterus after two to four days and drugs supporting the uterus are given. After approximately 15 days a pregnancy test will show whether the IVF treatment has been successful or not.