Infertility

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.

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;
• Anatomical obstructions;
• 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.

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.

(PCOS) Polycystic Ovarian Disease (PCOD) – The new epidemic ?

• One out of every four girls suffers from it. It causes all the problems that she most detests – weight gain, acne, facial hair growth and irregular periods. Not only young girls but even middle aged women may be affected by the problem of PCOD.
• This is a problem that often runs in families and the mother and daughters may both be affected as there is a strong genetic component in its inheritance. One of the main problems in PCOD or Polycystic Ovarian Syndrome (PCOS) as it is now called – is resistance to insulin.
• As the person usually has high insulin levels – she has a tendency to gain weight and to develop diabetes as she grows older. Also, as there is a problem of anovulation the ovary does not produce eggs every month, hence the girl suffers from irregular periods (usually delayed) scanty or heavy flow and often has difficulty in conceiving. Due to the excess of male hormone in the system, there is acne and excess facial hair growth. Some girls with PCOS may be thin and not show acne etc but sonography will show ovaries with multiple small water filed cysts thus establishing the diagnosis. Also a hormone check will show high levels of male hormone and also high levels of insulin. As a result of abnormal hormones and irregular periods for many years, these women have a higher chance of developing cancer of the womb.
• The treatment of PCOS depends a lot on the symptoms the patient has. The most important thing in the obese patients is weight loss as it significantly improves the entire picture. Lifestyle change is necessary which includes improvement in diet, increase in exercise and keeping weight in control.
• For a young lady who has lot of pimples and facial hair and has irregular periods the best treatment is combined hormonal pill. Some of these drugs contain medicines which reduce facial hair growth and within a few months the patient has significant improvement. The existing facial hair can be treated cosmetically, and new growth will reduce. Also pimples will clear out and menses will become absolutely regular with regular hormone treatment.
• The other group of women in whom conceiving is the major problem the treatment is totally different. They require medicines such as clomiphene or gonadotrophin injections to induce ovulation. Sonography is done to check if the egg is coming out every month or not (ovulation). Many of these patients have a very erratic response to drugs, either no effect or an excessive number of eggs growing in response to normal dose of medicines. Hence great care has to be taken when these women are treated for infertility. Many of these women become pregnant either with simple treatment or with test tube baby treatment (IVF) but there is also a high miscarriage rate in women with PCOS.
• A good drug in these women with high insulin levels is metformin, an antidiabetic drug but which has been proven to improve the metabolism and help weight loss in obese PCOS patents even when their sugar levels are normal. Another treatment for patients with many cysts in their ovaries is laparoscopic burning of the cysts with a thin needle through which a current is passed (laparoscopic ovarian drilling). This is a simple short procedure and requires 2 – 3 small (1 cm) cuts on the belly through which the laparoscope (telescope) and camera are passed. As the cysts are burned, the male hormone levels fall and the patient may begin to ovulate spontaneously. This is a good technique especially in infertile patients where the tubes also have to be checked to see if they are open or not, as the procedures can be combined.
• The problem of polycystic ovaries is massive; the important point is to have a healthy lifestyle with a good diet and exercise which will help to control this epidemic.

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 (gynaecological 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).

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.

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 gynaecologists 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.

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.

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.

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 level

Hope for childless couples.

• Infertility is the inability to conceive after one year of trying. Millions of couples in India suffer from depression, anxiety and the stress of trying unsuccessfully to become parents.
There can be many causes for this. In 40 – 50% of couples, the husband has a poor sperm count or live sperms may be absent in the semen and the only way to check it is by doing a semen analysis. There are many remedies for this problem, especially ICSI (Intracyotoplasmic Sperm Injection) where one sperm is injected directly into the egg which is removed from the wife, has given hope to many couples with severe male factor infertility.
• Donor sperm which is tested for all infections, is now freely available with semen banks, and is a simple and inexpensive option for some couples.
• Women may have a problem becoming pregnant due to hormonal problems, blocked tubes or a damaged uterus. Once all tests including sonography and laparoscopy are done to check these, a treatment plan is worked out. This may include simple procedures using drugs to induce ovulation. (grow the eggs in the ovary) followed by intrauterine insemination (IUI). In women with blocked and damaged tubes usually the best option is test tube baby (IVF), which has very good results today.
• In older women or those with ovarian failure, borrowing an egg from a younger woman (egg donation) gives her the ability to bear her own child and experience the pleasures of motherhood. In women with a damaged or abnormal womb (uterus), surrogacy is a solution where another women can carry the couple’s genetic child.
Science has progressed so much today that most childless couples can avail of the technological advances to help them to become parents, if nature wills otherwise.

FAQ

Q.1.   I am 27 yrs old and married since 5 years but have not conceived yet. When we did our basic tests, my reports were normal but my husband had no sperms in the semen. How could this have happened as he is otherwise totally healthy and normal? Can we ever have children? I am very upset and depressed.

Ans:   There can be many reasons for absent sperms in the semen (Azoospermia). He could be born with absence of the tubes which carry the sperms from the testes (absent Vas) or these tubes could have gotten blocked following an infection. In some cases, there can be testicular failure and there is no sperm production by the testes. This may result from some childhood infection such as mumps or other unknown causes. He needs to do a semen FSH level, which will help find out if he has failure of the testes and also an examination by an andrologist. You can become pregnant in all likelihood by test tube baby procedure (ICSI) after your husband’s sperms are obtained by putting a needle into the testes or the tubes (epididymis) draining it. Even in cases of testicular failure, many times sperms can be obtained by biopsy of the testes.

If all these techniques still do not yield any sperms, then the only option is to use donor sperms. All good test tube baby centres (IVF centres) have a semen bank where tested and checked semen is stored which can be used for insemination.
Q.2.   I am 27 years old, married for 4 years and have been trying for a baby since then. I have always had irregular periods and am overweight. My husbands semen report is normal. I am desperate, please help.

Ans:   It is possible that you have polycystic ovarian syndrome (PCOS) and sometimes acne and excessive facial hair growth. If these patients the egg does not come out every month, as a result some patients have difficulty in conceiving, sonography check ovulation. There are many tablets and injections available which help the eggs to grow. Sonography (follicle study) will check the growth and the exact time of rupture of egg. At this time if an insemination of husband semen is done the pregnancy rate is higher than with keeping normal relations. Ofcourse for all this you need to have normal open tubes which need to be tested bh an X ray (HSG) or laproscopy. (Keyhole surgery to look at the womb and the tubes etc.)

Q.3.   I am age 35 and married since last 5 years, We have been trying for a baby for the past three year, but all our efforts were in vain. I have done the necessary investigations and the reports were found to be normal. My husbands semen report shows Azoospermia. Please advice on what needs to be done and how I should proceed.

Ans:   Am sure you must have done a serum FSH level. If that is more or less normal, we can obtain sperms by Biopsy (Microscopic) of the testes. This can be used during the ICSI (Test tube baby) procedure and your wife may be able to achieve a pregnancy. We have had excellent results in Azoospermic patients by this technique.

If you can come to Mumbai for a preliminary check for a few days we can give you all the details and do the tests to confirm presence of sperms.

Q.4.   I am 30 years old and have been trying for pregnancy for 3 years without success. I have done sonography and had intercourse at the correct time but have not conceived. Please advice.

Ans:   As you are already 30, you must not waste much time but get all your investigations done including laparoscopy and hysteroscopy, in which the womb and the tubes and ovary are thoroughly checked and if there is any problem it can often be treated at the same session. Your husband’s semen report needs to be checked. If your tubes are open, then medicines to produce eggs combined with an insemination (IUI) gives good results. If your tubes are blocked or your husband’s semen report is low, then IVF or ICSI (test tube baby) is the best option for you. Please consult an infertility specialist for further management.

Q.5.   I have been married for 4 years and have not become pregnant yet. I am very keen to have a baby soon. My gynaecologist has told me to have a laparoscopy. What exactly is it and is it a painful procedure?

Ans:   If a couple is unable to conceive after one year of trying, basic tests of both should be done. The most important is semen test of the husband and checking to see if the tubes are open, in the woman. This checking of the tubes is done by laparoscopy. Laparoscopy is a simple short procedure in which a thin tube with a camera is introduced into the stomach through a 1 cm cut near the belly button (umbilicus). The entire womb and tubes can be checked by this. If there is any problem such as fibroid, cyst, endometriosis etc, it can be operated at the same time. The Diagnostic laparoscopy takes 20 minutes to perform and the patient can go home from hospital in a few hours. There is not much pain as the procedure is done under general anaesthesia.

Q.6.   I am 36 years old and have undergone a Uterine Balloon Therapy last year. I had been Diabetic / Hypertensive and had been suffering from heavy menses. But unfortunately I have lost my child. We have been told that there are many options now a days and have heard about IVF/ Surrogate mother but we want to know if there is some possibility left were in I can bear the child of my own.

Ans:   It is a terrible tragedy which you are going through. The best option for your wife will be to try IVF with surrogacy. After Balloon ablation the uterus is too damaged to bear a child, however at 39 years the possibility of getting eggs from the ovary is good. This should be done at the earliest possible considering the age.