Infertility is the inability to conceive a child. A couple may be considered infertile if, after one year of regular sexual intercourse, without contraception, the woman has not become pregnant. Primary infertility is infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a previous pregnancy. Female causes contribute 40% of infertility, 40% by male. In about 20% of couples with infertility problems, no diagnosis can be made for the cause of the fertility problem — this is called unexplained infertility. Fortunately, advances in reproductive medical care have made it possible to treat most explained and unexplained fertility problems.
Ovulation is the release of a mature egg from the female ovary; the release enables the egg to be fertilized by the male sperm cells. Normally, in humans, only one egg is released at one time; occasionally, two or more erupt during the menstrual cycle. The egg erupts from the ovary on the 14th to 16th day of the approximately 28-day menstrual cycle. If not fertilized, the egg is passed from the reproductive tract during menstrual bleeding, which starts about two weeks after ovulation. Occasionally, cycles occur in which an egg is not released; these are called anovulatory cycles.
People who are concerned about their fertility should be informed that about 84% of couples in the general population will conceive within 1 year if they do not use contraception and have regular sexual intercourse. Of those who do not conceive in the first year, about half will do so in the second year (cumulative pregnancy rate 92%). People who are concerned about their fertility should be informed that female fertility declines with age, but that the effect of age on male fertility is less clear. With regular unprotected sexual intercourse, 94% of fertile women aged 35 years, and 77% of those aged 38 years, will conceive after 3 years of trying.
Ageing of the ovaries is the most prominent factor and is part of the normal ageing changes that effect all organs and tissues. Most women have about 300,000 eggs in their ovaries at puberty. For each egg that matures and is released [ovulated] during the menstrual cycle; atleast 500 eggs do not mature and are absorbed by the body. By the time the woman reaches menopause which usually occurs between 50-55 years, there are only several thousands eggs remaining. As the women ages, the remaining eggs in her ovaries. Also age, making them less capable of fertilization and their embryos less capable of implantation.
OVARIAN RESERVE and AMH:
Ovarian Reserve (OR) is a term which describes the functional potential of the ovary, which constitutes the size of the ovarian follicle pool and reflects the number and quality of the oocytes which are within it. Assessment of the OR helps in reflecting the reproductive potential of women. Various markers are available for assessing the OR and the best marker is the Anti Mullerian Hormone (AMH) which reflects the ovarian follicular pool in the ovary.
Polycystic ovary syndrome (PCOS)
is one of the most common female endocrine disorders. PCOS is a complex, heterogeneous disorder of uncertain cause. But there is strong evidence that it can, to a large degree, be classified as a genetic disease. It affects approximately 5% to 10% of women of reproductive age (12–45) years old.
- Menstrual irregularities: PCOS mostly produces few menstrual periods or no menstrual periods or very frequent menstrual periods, but other types of menstrual disorders may also occur. Infertility, directly results from lack of ovulation.
- Most common signs are acne and hirsutism (male pattern of hair growth like upperlip, chin, side locks etc).
- Hyperpigmentation in areas like nape of neck, axillary regions, inner side of thighs etc.
- Increased weight gain leading to overweight and obesity.
ELEVATED PROLACTIN (HYPERPROLACTINEMIA):
Hyperprolactinemia is the excessive production of prolactin (the hormone responsible for milk production). High levels of prolactin can suppress ovulation or cause irregular menstrual cycles. The main symptoms that women experience are producing breast milk without being pregnant or nursing, and irregular or absent menstrual periods.
Both overactive (hyperthyroid) and underactive (hypothyroid) thyroid glands can cause changes in the menstrual cycle and prevent egg release. Thyroid disease is common and affects women eight times more often than men. Symptoms are very non-specific. Many a times it is detected when thyroid hormone profile is done as a part of screening. Low thyroid hormone (hypothyroidism) causes symptoms such as dry skin, fatigue, cold intolerance, weight gain and constipation. Excessive thyroid hormone production (hyperthyroidism) causes symptoms such as anxiety, tremors, weakness, rapid heart beat, weight loss and frequent bowel movements. Hyperthyroidism and hypothyroidism are both treated with medications. Surgery is rarely required for thyroid adenomas.
PREMATURE OVARIAN FAILURE:
POF is defined by abnormally low levels of estrogen and high levels of FSH, which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. The age of 40 was chosen as the cut-off point for a diagnosis of POF. Some women with POF can go into early menopause in their twenties. On average, the ovaries supply a woman with eggs until age 51, the average age of natural menopause. The circulating levels of FSH will be high(>40mIU/ml) and that of estrogen will be low. Women with POF may have any of the natural signs and symptoms of menopause.
- Irregular or absent periods
- Hot flashes
- Sleeping problems
- Mood swings
- Problems with concentration or memory
- Vaginal dryness, Painful intercourse
- Low sex drive
- Loss of energy
Genetic disorders, autoimmune damage, chemotherapy, radiation to the pelvic region, surgery, endometriosis, infection, autoimmune diseases.
Symptoms can be relieved with medicines but for women trying to get pregnant, the only reliable way of conceiving is to have IVF using donor eggs from a young healthy donor.
FALLOPIAN TUBE BLOCKAGE:
Tubal blockage is a common form of infertility where the fallopian tubes are blocked or scarred. Consequently, sperm and egg may never meet, embryos can be trapped in the tube (ectopic pregnancy) or tubal fluid can flow back into the uterus preventing embryos from implanting. The main cause of damage to tubes is an infection. The most common infections are chlamydia and gonorrhea. Other causes of tubal damage include: Appendicitis, Previous ectopic pregnancy, Endometriosis, Scar tissue from abdominal surgery, Tuberculosis, Congenital conditions The treatment of tubal infertility depends on many factors including the cause and location of the damage. If only one tube is blocked and no hydrosalpinx is present, no treatment may be necessary. Previously laparoscopic surgery or tubal cannulation procedures were used to open or repair the tubes. If both tubes are blocked and cannot be repaired, in vitro fertilization (IVF) is the best treatment option.
Fibroids: One out of every four or five women in their 30s and 40s has a uterine fibroid. Fibroids are benign growths of the uterus also known as myomas. They are dense growths of muscle cells of the uterus somewhat like a knot in a piece of wood. They may protrude from the inside or outside surface of the uterus. They are often multiple and can vary in size from quite small to up to 10 cm or more in diameter.
Fibroids can impair fertility by:
- Large fibroids in the wall of the uterus can occasionally block the Fallopian tubes
- Growing into the uterine cavity preventing an embryo from implanting or causing early miscarriage
The impact that fibroids have on fertility depends upon their size and location.
Many women have uterine abnormalities with no negative effect on their fertility. In some cases, however, an abnormality of the uterus can affect a woman’s ability to get pregnant or carry a pregnancy to term.
- Scarring of the uterine cavity (aka Asherman syndrome) — Scarring can result from uterine surgery (e.g. a D&C) or infection.
- Septate uterus – The uterus is divided in half by a thin wall.
- Bicornuate uterus—The uterus is heart-shaped and the cavity is divided into two chambers by a thick muscular wall.
- Unicornuate uterus—Only half the uterus has formed. The uterus is small and located on one side of the pelvis only. There is usually only one Fallopian tube.
Symptoms and tests:
Often, women have no symptoms of a uterine abnormality aside from difficulty in getting pregnant or recurrent miscarriages. Some women will have painful or heavy periods. Physicians have several tests they can use to diagnose these conditions, such as a hysterosalpingogram , laparoscopy, hysteroscopy, ultrasound and MRI. CausesUterine abnormalities can be genetic or drug-induced. In the 1950s, the drug diethylstilbestrol (DES) was prescribed to prevent miscarriages, and many of the daughters of women who took DES were born with these uterine defects. Currently, very few women of reproductive age have been exposed as DES was withdrawn from the market in the early 1970s.
Some uterine conditions can be corrected with surgery; however, for others, there is no treatment that can improve fertility or pregnancy outcomes
Each month your body, in preparation for pregnancy, creates a lining for the uterus called the endometrium. If pregnancy does not occur, the uterus sheds the lining and the tissue passes through the body in the form of menstrual bleeding. Endometriosis is a common condition in which the endometrium grows and spreads outside the uterus. The endometrial tissue may then implant on the ovaries, the outside of the uterus, and other abdominal organs. These deposits bleed every month with the menses and are quickly surrounded by an inflammatory reaction as the body tries to “wall off” the bleeding deposit. The inflammation and bleeding around the deposits of endometriosis create an unfavourable environment for eggs and sperm. The inflammation may cause scar tissue (adhesions) to form that can prevent the eggs from reaching the fallopian tubes or even block the tubes.
Up to 10% of infertile couples are diagnosed with unexplained infertility. This simply means that conventional fertility tests for both partners don’t reveal the cause of the couple’s infertility. This is an extremely frustrating diagnosis. But just because we are unable to diagnose the cause of your infertility doesn’t mean we can’t treat it.
There are a range of treatment options, including:
- Fertility drugs such as clomiphene citrate, or follicle-stimulating hormone (FSH)
- Intrauterine insemination (IUI) (artificial insemination of sperm into the uterus)
- In vitro fertilization (IVF)