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INFERTILITY BASICS

Sunday, November 3, 2019

INTRODUCTION

The problem of infertility is still not openly addressed in our society. Infertility can be a devastating experience which can change every aspect of a couple’s life. Indeed few health conditions could more profoundly affect a person’s well being than infertility.

It is important to understand that infertility can be treatable. Having a basic knowledge about fertility issues is the best way to take the first step towards prevention and to seek medical assistance if faced with the problem.


What is infertility?

Infertility is defined as inability to conceive a child despite trying for one year.


When should a couple seek medical help?

Eighty five percent of couples are successful in achieving a pregnancy by the end of first year and a further 5-7% will do over the next year. Hence it is reasonable to take medical assistance if a couple has not been successful in achieving a pregnancy in one year. However, if the female age is advanced or there are other issues such as irregular periods it is advisable to obtain assistance earlier.


How common is the problem?

It is a common condition that affects one in 6 couples.


Incidence –is it on the rise?

There is evidence to suggest that the incidence is increasing. This is mainly due to life style changes in the west which is also applicable to the urban population in India such as late marriages and delayed child bearing. Secondly, there is an increase in the incidence of obesity worldwide which reduces fertility and also causes hormonal disturbances interfering with ovulation. Increase in the incidence of sexually transmitted diseases (STD) and a general decline in male fertility also contributes to the problem.


Is infertility mainly a female problem?

It is a myth that infertility is always considered a woman’s problem. Infertility is caused by a female factor in 35% of cases, male factor in another 35% and because of a combined problem in both in the rest.


What are some of the causes of infertility?

The main causes of infertility in women are:

  • Ovulation disorders-A common cause of infertility in women is due to hormonal disorder which upsets the normal reproductive cycle and ovulation does not take place. This leads to irregular menstrual cycles. The commonest cause of ovulation disorder is caused by a condition such as Polycystic Ovarian Syndrome (PCOS).
  • Tubal factor-Eggs are picked up by the fallopian tube and fertilization (process of forming the embryo when egg and sperm meet) occurs in the distal end of the fallopian tube. If the tube is blocked or damaged then fertility is impaired. The commonest cause of tubal damage is sexually transmitted infection or infection occurring following abortion. In India, genital tuberculosis is common and is an important cause of infertility.
  • Endometriosis—is a common condition that can affect the ovaries, tubes where the endometrial (womb lining) tissue can attach to an organ causing inflammation and scarring.
  • Unexplained—where routine tests do not reveal any abnormality in the couple. This could be due to subtle defects in the process of ovulation or fertilization.


Age and fertility

Incidence of infertility increases as female age increases reflecting the normal decline in egg quality. Older women are also more likely to suffer a miscarriage or have a child with a chromosomal abnormality than their younger counterparts. Women above the age of 40 even with assisted reproductive techniques (ART) have far less success rates.

Unfortunately in the current climate, many women are choosing to have children later in life after they have established their careers and have financial security. However, the biological clock does not match these socio economic choices. The peak fertility for women is between 20 to 25 years of age. Fertility starts declining in the thirties and there is a sharp fall in fertility once a woman reaches 35 years of age.


What are the causes of male infertility?

Life style issues such as smoking, alcohol, stress and obesity can all have a negative influence on the sperm count. The other causes of male infertility are hormonal problems, obstruction of the male reproductive tract due to sexually transmitted disease or tuberculosis or surgery. Congenital or genetic causes such as Klinefelter’s syndrome (chromosomal abnormality) or genetic conditions related to deletion of genes from Y chromosome (male chromosome) may also give rise to male infertility.

However about 40% of men with infertility present with abnormal semen analysis for idiopathic reasons and for these men no specific treatment is available and Assisted Reproductive Technologies such as IUI/IVF are the way forward.


What are the common tests to be done in the evaluation of the infertile couple?

Modern infertility treatment focuses on the couple together and is essential that both the woman and man need to be evaluated during an infertility workup.

The initial investigations are semen analysis in the male. If sperm count is low, additional blood-hormone levels and genetic tests could be arranged. In the female, hormonal blood tests, assessment of ovulation, checking tubal patency either in the form of X-ray test or laparoscopy (key hole surgery) is initially needed. Additional tests could be arranged if needed.

What are the treatment options available?Couples experiencing fertility problems should ideally be treated by a specialist team as this is likely to improve the effectiveness and efficiency of treatment and this is definitely known to improve patient satisfaction.

The common treatment options in the female are ovulation induction, laparoscopic surgery for mild tubal disease and endometriosis and Assisted reproductive technologies such as IUI (Intra Uterine Insemination) and IVF (test tube baby). The main treatment options for male infertility are assisted reproduction treatment in the form of IUI, IVF and ICSI (Intra Cytoplasmic Sperm Injection) depending on the severity of the problem.


Why is counseling important in infertile couples?

The desire to have a child is natural and when conception does not occur a life crisis may be provoked. Childlessness may evoke strong feelings of anger, shame, guilt, powerlessness and despair. Relationships with partner, family members and friends may become strained leading to a breakdown in communication and feelings of isolation.

Counselling provides time and space for patients, whether asindividuals or as couples, to talk over concerns about fertility problems and treatments. It can help in coping with stress and the effects that difficulties in conceiving may have on relationships.


How successful is fertility treatment?

A diagnosis of infertility does not have to mean childlessness. It can often just mean that becoming pregnant is a challenge-one that can be aided significantly by medical treatment. Recently improvements in assisted reproductive techniques and treatment options available for infertility have greatly increased the chance of treatment success in sub fertile couples. Approximately 75% of couples presenting for fertility treatment are successful in achieving a pregnancy over a period of time.


DR.S.VYJAYANTHI, MD, DGO, DNB, MRCOG (London), MSc (Embryology) (UK)

Head of Department and Consultant in Infertility, Reproductive Medicine and Surgery

Krishna Institute of Medical Sciences

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