What is Infertility?
Infertility may be defined as the inability of a couple to conceive after one year (six months if the woman’s age is more than 35) of regular sexual intercourse, without the use of contraceptives. While the cause may lie in either partner, in some cases no definite cause for infertility can be identified. This is also known as primary infertility.
Secondary infertility is the inability to conceive or carry a pregnancy to term after successfully conceiving one or more children. The causes of secondary infertility tend to be the same as those for primary infertility. Sterility is a term used loosely but indicates the total inability to conceive, in other words, you can never fall pregnant or impregnate a woman. The causes of sterility are the same as infertility.
Overall, women are more proactive about addressing the issue of infertility and will seek treatment when necessary. However, as a woman, the problem may not lie with you and it is also important to understand the causes of male infertility, so as to assist your partner accordingly.
Causes of Female Infertility
- Fallopian tube damage or blockage may prevent eggs from reaching the uterus or sperms from reaching the eggs. This may occur due to salpingitis (inflammation of the fallopian tube), the most common cause of which is chlamydia, a sexually transmitted disease, pelvic inflammatory disease, previous surgery for sterilization, and earlier ectopic pregnancy.
- Endometriosis is implantation and growth of uterine tissue outside the uterus, such as in the ovary, pelvic peritoneum or any other site, and is a common cause for infertility.
- Ovulation disorders is any condition, usually hormonal, which prevents release of mature eggs from the ovary (anovulation).
- Poor egg quality is usually related to age of the woman. After the age of 35 there are more chances of the ovum developing chromosomal abnormalities which disallows continuation of pregnancy.
- Polycystic ovary syndrome are multiple cysts in the ovary, which cause a hormonal imbalance and irregular ovulation.
- Hyperprolactinemia refers to high levels of prolactin, often an indication of a pituitary tumor, and this state affects ovulation, which may result in infertility.
- Premature ovarian failure or early menopause may occur before the age of 40, often due to unknown causes, but may also be associated with immune system disease, radiation, chemotherapy, or smoking.
- Hostile cervical mucus.
- Pelvic adhesions are bands of scar tissues that may form in the pelvis after pelvic infection or surgery, and may be the cause for infertility.
- Uterine fibroids are benign tumors in the uterus which may cause infertility by preventing implantation of the fertilized ovum in the uterine wall.
- Thyroid disorders such as hypothyroidism or hyperthyroidism.
- Cancer, especially of the reproductive system, and its treatment by radiation or chemotherapy.
- Medical conditions such as Cushing’s disease, sickle cell disease, diabetes, and kidney disease.
- Smoking and excessive caffeine consumption.
- Genetic defects.
Causes of Male Infertility
- Low sperm count or complete absence of sperm production by the testes (azoospermia).
- Impaired morphology (shape and structure) or motility of the sperm.
- Undescended testes
- Testosterone (male hormone) deficiency
- Genetic defects
- Infections like sexually transmitted disease, such as chlamydia, or childhood diseases, such as mumps before puberty.
- Erectile dysfunction, premature ejaculation, or psychological problems.
- Absence of semen
- Blockage of ejaculatory ducts
- Hypospadius is a birth defect where the urinary opening is on the underside of the penis.
- Substance abuse, smoking, alcohol or drug dependency, and exposure to chemicals such as lead.
There are a number of infertility treatment options but the most suitable course of action will depend on the cause of infertility, coupled with the individual’s state of health and cost considerations.
Fertility tests are done to determine the cause of infertility and whether the problem lies with the male or female partner or both. After proper history taking and physical examination, the following tests and procedures are advised :
- complete blood count
- grouping and Rhesus factor
- German measles (rubella)
- hepatitis B
Based on the results of these tests, further special testing and other investigative procedures may be necessary for each partner. The findings will determine the appropriate infertility treatment that should be considered for the individual or couple.
Infertility Tests for Men
- Semen analysis is when a specimen of semen is collected and analyzed in the laboratory, particularly for sperm count, morphology (shape and structure), and motility (movement) of the sperm.
- Hormone testing is a blood test to evaluate the level of testosterone and other male hormones.
Infertility Tests for Women
Fertility Blood Tests
Blood tests are done to evaluate the levels of various hormones affecting the reproductive process. Interpretation of the results depend on the day of the menstrual cycle when the blood sample was taken. Some of hormones tested may include :
- Follicle stimulating hormone (FSH) which is secreted by the pituitary gland and its level increases as a woman approaches menopause and the ovaries show signs of aging.
- Luteinizing hormone (LH) controls egg development, but consistently high levels of this hormone hinders this process.
The two tests above are done on the third day of the menstrual cycle. A second hormone evaluation may be done one or two days before ovulation, when FSH and LH levels are measured again. High levels of FSH and LH may be a sign of ovarian problems, while low levels may indicate a pituitary or hypothalamic disorders.
Other tests may monitor or test the following :
- Estradiol level in the blood often detects a decrease in egg quantity and quality even though the day 3 FSH level is normal.
- Clomiphene challenge test can detect poor ovarian reserve even when the day 3 FSH level is normal. This test is done by noting the day 3 FSH and estradiol levels, taking 2 tablets of clomiphene (100 mg) on days 5 to 9 of the menstrual cycle, and repeating FSH level on day 10. The result is taken as normal if FSH and estradiol levels are low on day 3 and FSH level is also low on day 10.
- Prolactin levels if high inhibits release of FSH and LH, preventing ovulation.
- Thyroid function tests to exclude thyroid disease as the cause of infertility.
- Progesterone test is done around day 21 of the menstrual cycle and a high level of progesterone confirms ovulation.
Other diagnostic procedures may also be conducted to verify other factors that may contribute to infertility in women.
- Pelvic ultrasound is done to determine size and structure of the uterus and ovaries and detect conditions such as uterine fibroid.
- Hysterosalpingogram is an x-ray test to see the inside of the tubes and uterus to detect tubal blockage or any other abnormality in the tubes or uterus.
- Laparoscopy is when a tiny incision near the umbilicus allows a thin lighted tube to be put inside the abdomen to view the woman’s pelvic organs. Possible causes of infertility such as adhesions, cysts, fibroid, and endometriosis can be diagnosed.
- Endometrial biopsy is when a small sample of uterine tissue is used to check if normal changes are taking place in the endometrium during the menstrual cycle.
- Karyotype or Genetic tests. Karyotyping may be necessary to look for problems in the genetic material (chromosomes) of the cells and genetic tests may help to find the cause of infertility or frequent abortions.
There are various options available for treatment of infertility such as fertility drugs, surgery, artificial insemination, assisted reproductive technology, or a combination of these, and obviously the treatment of choice will depend on the causes of infertility as well as on the couple’s personal preferences. The success of the various infertility treatment options may differ and is dependent on each individual case.
Infertility Treatment for Women
Fertility drugs help by inducing or regulating ovulation in women who are infertile due to ovarian dysfunction. These drugs include :
- Clomiphene which is taken orally and helps to stimulate ovulation in women. It is particularly useful in cases of polycystic ovary syndrome (PCOS) and other ovulation disorders and works by acting on the pituitary gland.
- Human menopausal gonadotropin (hMG) is given in as an injection and directly stimulates the ovaries in case of pituitary gland failure.
- Follicle stimulating hormone (FSH) stimulates the ovaries to mature egg follicles.
- Human chorionic gonadotropin HCG).
- Metformin is used when insulin resistance is the cause of infertility.
- Bromocriptine inhibits prolactin secretion and is helpful in cases of hyperprolactinemia causing infertility.
The main side effect of fertility drugs is the possibility of multiple pregnancies.
Surgical intervention may be considered in the following cases :
- Blockage in the fallopian tube.
- Genetic defects in the reproductive system.
- Uterine fibroid.
- Ovarian cysts
Assisted reproductive technology (ART)
This form of treatment for infertility allows couples to have their own biological baby, and chances of success are more in a woman with a healthy uterus, with a good response to fertility drugs, who ovulates normally or uses eggs from a donor. Healthy sperm from the male partner or a donor is necessary. The various forms of ART include :
- Artificial insemination where a concentrated amount of healthy sperm from the partner or a donor is introduced into the uterus by means of a catheter.
- In vitro fertilization (IVF) where mature eggs are fertilized with sperm in a laboratory dish, and is then implanted into the uterus three to five days after fertilization.
- Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer is similar to IVF but the embryo is transferred to the fallopian tube instead of the uterus.
- Gamete intrafallopian transfer (GIFT) when eggs and sperms are transferred to the fallopian tube so that fertilization occurs inside the woman’s body.
- Intracytoplasmic sperm injection (ICSI) is the method where a single sperm is injected into a mature egg to obtain fertilization and is especially helpful in men with low sperm count.
- Embryo donation is where an embryo or egg from a donor is fertilized with sperm and implanted into the uterus.
- Surrogacy is when a couple’s embryo or a donor embryo is carried by a surrogate mother.
Infertility Treatment for Men
Difficulty in conceiving may lie with the male partner and may require similar procedures as for women. The main approach to treating infertility in men includes :
- Treating sexual problems such as impotence or premature ejaculation by medicines or counseling.
- Hormone treatment, surgery, or assisted reproductive technology (ART) can help treat infertility in men, depending upon the cause.