General information about infertility
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1. What is infertility?
Infertility, whether male or female, can be defined as 'the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse'.
2. What is the incidence of infertility worldwide?
The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problems. On a worldwide scale, this means that 50-80 million people suffer from infertility. However, the incidence of infertility may vary from region to region.
3. Is infertility exclusively a female problem?
No. The incidence of infertility in men and women is almost identical. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 30-40% of the cases. Problems common to both partners are diagnosed in 10-15% of infertile couples. After thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%). This is called unexplained infertility.
4. What are the most common causes of infertility?
The most common causes of female infertility are ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes. Less frequent causes include, for example, endometriosis and hyperprolactinemia, thyroid gland related problems.
In developing countries like India, infections of the womb such as gonorrhoea, chlamydia and tuberculosis significantly, contribute to infertility.
Causes of male infertility can be divided into three main categories:
Sperm production disorders affecting the quality and/or the quantity of sperm;
Other factors such immunological disorders.
Approximately a third of all cases of male infertility can be attributed to immune or endocrine problems, as well as to a failure of the testes to respond to the hormonal stimulation triggering sperm production. However, in a great number of cases of male infertility due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.
5. Ectopic Pregnancy
When a pregnancy is not located in the uterus it is called an Extra Uterine Pregnancy (EUG) or ectopic pregnancy.
The most common place for an EUG is the fallopian tube but sometimes the ectopic pregnancy is located elsewhere, such as in the cervix, the ovary or in the abdomen. EUG is a rare disease and occurs in 1% of all pregnancies. With IVF treatment the risk can increase. Risk factors for EUG are a history of infection of the tubes (Salpingitis), Chlamydia infection, Pelvic Inflammatory Disease (PID), genital tuberculosis, former EUG, operation on the tubes or in the lower abdomen, endometrioses and appendicitis.
The symptoms of ectopic pregnancy are often similar to those of a normal miscarriage and may include a positive pregnancy test together with or without vaginal bleeding and abdominal pain. Although it is not common, the possibility of EUG has to be considered in patients with the symptoms and one (or more) of the risk factors for EUG. Diagnoses is made by questioning the patient on the risk factors, physical examination, vaginal ultrasound and laboratory findings, especially the serum BHCG levels.
Depending on the size and the location of the EUG, different treatments can be given. Nowadays, most of the ectopic pregnancies can be removed surgically by Laparoscope, without opening the abdomen. But occasionally medical treatment in the form of Methotrexate injection or expectant treatment is offered when the pregnancy is very small and thorough control of the patient is possible. Alternatively, one can directly inject drugs into the ectopic pregnancy, making use of a thin needle, under the guidance of Tranvaginal Sonography.
Polycystic ovary syndrome or shortly PCOS, is an ovulation disorder which affects 4-6% of all women. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic.
The major features of this syndrome are irregular or no menstruation, Hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound.
Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focused on regulation of the menstrual cycle. For this, several drugs are used (Clomiphene Citrate, Bromocriptine, Gonadotrophins) and weight loss is bly advised.
In many cases the cycle will be ovulatory and regulated by these treatments. Newer oral anti diabetic drugs such as Metformin are being more frequently used to treat PCOS, with very good outcome. Alternately, one can Electrocoagulate the ovarian surface using a laparoscope, especially in those women with highly elevated levels of LH hormone.
If these women fail to become pregnant, they may be subjected to Gonadotropin injections, to stimulate ovulation. This may be combined with an Intrauterine insemination procedure (IUI) . Resistant cases may be treated by performing ART procedures such as IVF or ICSI.
7. What are the causes of damaged fallopian tubes?
In the beginning In Vitro Fertilisation (IVF) was developed for patients facing infertility due to damaged fallopian tubes. Later on the indications to perform IVF was broadened with for example unexplained infertility and male infertility.
Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection. In developing countries such as India, the biggest culprit is Genital Tuberculosis, in which the womb of the patient is infected by the tuberculosis germ. For the tubes this is mostly due to sexually transmitted diseases (for example Chlamydia or Gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes.
Other causes are abdominal operations (gynecological operations, cesarean section, sterilization or other) and internal diseases like Crohn's disease. Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).
8. Cystic fibrosis and male infertility
Men who have cystic fibrosis often have a congenital anomaly in the male genital tract. The vas deferens, the tube connecting the testicle and epididymis to the ejaculatory duct is congenitally absent.
This makes it impossible for the sperm to pass through the penis. Using testicular sperm aspiration, the urologist can obtain sufficient sperm to allow excellent success with IVF and ICSI (Intracytoplasmic Sperm Injection). Insufficient numbers of sperm are obtained to make intrauterine insemination an effective option.
As cystic fibrosis is recessive genetic disorder, abnormal gene contributions from both parents are necessary for this disorder to be present. Both copies of the gene are abnormal in men with CF. While persons carrying a single copy of an abnormal gene do not have this condition, when paired with a partner with CF, they have a 50% chance of CF in their offspring. This makes testing the female partner advisable. If the woman tests normal, the children will be carriers for an abnormal gene and although they will not likely have CF, it is advised that their spouses be checked for CF gene abnormalities.
Cystic fibrosis is more commonly seen in European populations. Its prevalence in Asian populations is relatively on the lower side.
9. What is Endometriosis?
Histologically identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well.
Endometriosis is one of the most common problems that gynecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories, we still do not have a clear understanding of the cause or of its relationship to infertility.
Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow. Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow.
By the same token, endometriosis may not be the cause of infertility, but the result of it. Further technological developments may be necessary in order for us to fully understand this problem.
Endometriosis is generally diagnosed at the time of Laparoscopy. Nowadays one can treat it by performing advanced Laparoscpic surgery using Lasers, electric current and scissors. In fact, with the advent of operative Laparoscopy, very few patients need to undergo the traditional method of opening the abdomen. Endometriosis can also be controlled (if not totally cured) by using various drugs such as Danazol, GnRh analogues or progesterones. The above mentioned treatments help many patients to become pregnant. The remaining patients may have to resort to IVF or ICSI. In our unit, we have found that ICSI gives better results than IVF.
10. What does Laparoscopy involve?
The laparoscope allows visual inspection of the pelvic organs through a very tiny incision. Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed Laparoscopically, in the outpatient setting.
11. What causes recurrent miscarriage
Recurrent miscarriage affects 1% of all women. The incidence of pregnancy loss among all women is about 15%. If the first pregnancy ended in miscarriage, there is only a slightly increased chance (18%) of this happening again second time round. However, after two miscarriages, this risk rises to 25-30%. For this reason, most doctors now recommend that a woman see a fertility specialist if she has experienced two miscarriages in a row.
At least 50% of pregnancies that miscarry in the first three months are believed to have a major chromosomal abnormality. This rate remains high for pregnancies lost during the second trimester (30%) and drops to 5% for those lost in the last trimester. Other possible causes include problems relating to the immune system, hormone imbalances, abnormally shaped uterine cavity, and pelvic infections.
Studies have also linked the use of alcohol, cigarettes, and excessive caffeine consumption to an increased risk of miscarriage. For some 50% of couples with recurrent miscarriage no explanation will be found for the problem. When a woman consults a specialist about her recurring miscarriages, the doctor will first try to diagnose the cause. The treatment will depend on what was found. If, for example, the woman is found to have uterine fibroids or polyps (two types of benign growths) surgery may be performed to remove these. Similarly, if she has a uterine septum (a congenital condition in which the uterus has a wall through the middle of it), surgery can correct this. If blood tests find that she has a hormonal dysfunction known as "luteal phase defect" (not producing enough of the hormone progesterone to support an early pregnancy), she can be given progesterone vaginal suppositories. If the presence of an organism called "Ureaplasma" is found, an antibiotic will be prescribed. If there are immunologic factors, aspirin therapy in early pregnancy may be prescribed. And, although controversial due to possible side effects, some doctors use "heparin" therapy - a series of injections which lowers the body's immunity to the fetus. The other newer advance in the treatment, is in the form of immunotherapy, where the women are injected with the lympocyte cells derived from the husband.
12. Infertility after 40
It is generally accepted that fertility decreases with age. A woman in her twenties and thirties has a 20-25% chance of a naturally occurring pregnancy, but for a woman in her early forties this possibility decreases to 5%. In IVF therapy women over the age of 35 are seen twice as frequently compared with younger women. In fact, age is the most important factor in IVF success rates. Research has recently revealed that fertility decreases with age because of the declining quality of the woman's eggs.
Although it is not possible to improve the quality of the eggs, women in their forties (and fifties and sixties) can become pregnant using techniques which can improve IVF outcome. For example, increasing the doses of drugs used to induce ovulation will increase the number of eggs that develop in a given month, thereby increasing the chance that at least one egg will be fertilized and develop into a viable pregnancy.
The most consistently successful method to increase the chance of pregnancy in women with age-related infertility is egg donation from a relative or anonymous donor. To predict a woman's fertility two blood tests - FSH (Follicle Stimulating Hormone) and E-2 (Oestradiol) - can be carried out on the third day of the menstrual cycle. These assess a woman's "ovarian reserve", in other words whether she is still producing eggs and whether these are able to produce a pregnancy.
The higher the FSH, the less capable a woman's eggs are of producing a pregnancy. As a woman ages, her FSH levels increase, but younger women with poor quality eggs can also have high FSH levels.