What is Infertility?
Infertility can be explained in simple terms as the inability to get pregnant despite having unprotected sexual intercourse that is planned according to the menstrual cycle for over a year. It is a disease of the reproductive system that can affect males and females and has numerous causes. It affects approximately one in every six couples trying to get pregnant and thus is of great importance.
The following conditions must apply in order to declare a couple as infertile;
- The person must be of reproductive age; ideally between 15 to 49 years of age.
- The couple must be practising regular sexual intercourse with the desire to conceive a child- which means, they shouldn’t be using any forms of contraception including condoms, pills, etc, they should be timing the population such that it’s in accordance with the female ovarian cycle- ie during the period of ovulation and must’ve done the same for at least a period of twelve months.
- The woman mustn’t be lactating; within 6 months of a previous term pregnancy that may or may not have been completed with live birth of a child.
Primary Infertility and Secondary Infertility.
Infertility that is caused due to all three of the reasons listed below is known as ‘true infertility’-
> Sperm production and/or transfer is impaired
> Ova production is impaired
> The Fallopian tubes are defective and thus implantation of the fertilized egg isn’t possible.
Primary infertility is a condition where the woman has never been able to bear a child- either she has never been able to get pregnant or she hasn’t been able to maintain a pregnancy till delivery of a live newborn.
Women who have numerous miscarriages despite proper measures and care, those who haven’t been able to get pregnant despite multiple tries or whose pregnancy have resulted in stillborn children exclusively with no live birth fall under the category of primary infertility.
Secondary Infertility– This applies to women who have previously been able to get pregnant or carry a pregnancy up to live birth and are now unable to do so which can be due to multiple causes that we shall explore.
These women may already have one or more children from previous healthy pregnancies which means they were fertile prior to this and haven’t always been this way.
Infertility is not necessarily a permanent condition and must not be confused with sterility. To understand the difference we must know a bit more about sterility.
What is Sterility? Sterility is a permanent condition where the affected individual is not able to produce the sperm or ova that are the prime elements of sexual reproduction. Sterility isn’t reversible and sterile individuals do not have a chance of reproducing even with assistance- including surrogacy.
What Causes Infertility?
The causes of infertility differ among men and women, let’s explore both.
Female Infertility is marked by the following events and what causes them;
- Problems in the production of the ova- a process that is known as ovulation and takes place in the ovaries.
- Problems that can happen during the release of the ova- a defect in the Fallopian tubes
Let’s now look into what causes these problems-
Problems during the Stage of Ovulation
I. Hormonal Imbalances
The female hormones that regulate the menstrual cycle are estrogen and progesterone that are released under control of the FSH and LH. Other than these hormones like Cortisone and Thyroid Hormones influence the female reproductive system. Increased corticosteroid levels in the blood and hypothyroidism are known to reduce production of the female hormones and thus have a chance of rendering the affected individuals infertile or even sterile depending on the effects and duration.
Being grossly overweight adds stress to the body and causes diseases like Polycystic Ovarian Disease that is a condition of severe hormonal imbalance and is marked by many developed cysts (pus-filled structures) in the ovaries- that lead to infertility and other problems like hirsutism (excessive hair growth), irregular or lack of periods. While medicines may manage the condition, the only way to actually make a difference for the condition is to eat healthily and exercise in order to lose weight and reduce the stress on the ovaries.
III. Sudden Voluntary Loss of Weight
Trying to lose copious amounts of weight adds a lot of stress to the body especially if it’s in a very short period of time which forces the body to preserve any fat it has and this also leads to the excess release of cortisone which causes the above-mentioned problems.
IV. Alcohol abuse and using non prescribed drugs have shown to cause infertility.
Malignancies and benign tumors of the ovary can result in infertility by affecting the structure of the ovaries as well as the oocytes. They also lead to above mentioned hormonal changes and affect the cycles.
Problems that affect Implantation of the fertilized egg (in the Uterus and/or Fallopian Tubes)
A major infection that affects the uterus, Fallopian tubes, cervix and ovaries is the Pelvic Inflammatory Disease. It is transmitted through sexual contact and is treatable but occasionally the scars damage the tissue of the organs and leave them incapable of implantation.
II. Uterine Fibroids or Polyps
Although usually hereditary fibroids may occur spontaneously as well and are characterized by heavy bleeding. The ultimate remedy to cure fibroids is the removal of the uterus- a process is known as hysterectomy as the condition can turn into malignancy if left untreated while causing severe discomfort to the patient.
III. Previous Surgeries or Infections
These are likely to leave scars in the uterus that will affect the lining and make getting pregnant difficult.
IV. History of Ectopic Pregnancies
A fertilized egg ideally gets implanted in the uterus’ endometrial lining but if due to any reason, the zygote implants anywhere other than the endometrium then this is what’s known as an ectopic pregnancy. Previous incident of ectopic pregnancy in a person can result in repetition and infertility. This is also known as tubal pregnancy as the ectopic implantation usually occurs in the Fallopian tubes.
Diethylstilbestrol-DES was a drug popularly used in the 40’s to 70’ to treat miscarriages. Ironically, however, the future generations of the women who were treated with this drug showed signs of infertility.
Besides these, conditions that lead to the cervical mucosa being hostile lead to infertility in females.
Male Infertility- is characterized by the following
- Inability to produce spermatozoa
- Low sperm count in the semen
- Defective function of the sperms
- Poor transportation of the sperms
What Causes These?
I. Infectious Causes-
Sexually transmitted diseases such as Gonorrhoea or AIDS can cause inflammation in the structural organs of the male reproductive system such as the testes- orchitis or epididymitis. What happens in these conditions is that there’s usually severe scarring of the passage through which sperms are released and can even affect the health of the sperm as well as the motility and count.
Varicocele is an easily reversible condition where there’s inflammation of the vessels that drain blood from the testicular region. They cause defects in the sperm resulting in infertility.
III. Retrograde Ejaculation-
Retrograde Ejaculation instead of being ejaculated out of the urethra at the climax of sexual intercourse, the semen is transported into the bladder instead. Mostly this is seen in patients who suffer from spinal cord injuries, who have undergone surgeries of the urethra or prostate, long-term diabetes, etc.
IV. Autoimmune Conditions-
The body recognizes the sperm cells as foreign cells that are attacked by the immune system.
V. Obesity and Stress
Obesity and Stress lead to hormonal imbalances that result in infertility.
VI. Undescended Testicle
Undescended Testicle is a condition that happens to the male fetus where either one or both of the testicles fail to descend from the scrotum on their own and needs medical attention. Such individuals have a higher rate of infertility.
VII. Lack of Testosterone
Lack of Testosterone or any of the hormones that influence reproductive system can lead to infertility including the thyroid hormone.
Some More Reason For Male Infertility
- Trauma, tumors and after effects of Infections that result in the blocking of the pathway through which the sperm is transported from the testes. This blockage can be within the testes, the drainage pathway of the same, vas deferens, epididymis or urethra.
- Diseases like Cystic Fibrosis and Celiac Disease are shown to be in association with male infertility.
- Issues during sexual intercourse including premature ejaculation, erectile dysfunction, hypospadias- a condition where the opening at that’s usually at the tip of the penis lie at the bottom instead can all cause infertility in males.
- Alcohol abuse and use of recreational drugs result in infertility.
- Other Causes- Long-term medication with certain antibiotics, exposure to heavy metals such as lead, exposure to toxins such as pesticides, benzenes, overdosage of radiation including X-rays, wearing tight clothes, etc are known to cause low sperm counts and affect sperm motility.
Signs Of Infertility to Watch Out For
Now the clearest indication of infertility is a couple lies within the definition of the same-inability to achieve full-term pregnancy followed by live birth despite planned, unprotected sexual intercourse for at least 12 months.’
However individually, in men and women, there are a few noteworthy symptoms that can be observed.
Signs of Male Infertility
- Any sign of impotence such as erectile dysfunction.
- Any masses or swellings in the testicles.
- Signs that indicate hormonal imbalances such as the decreased growth of hair in the body.
- Lack of arousal.
Signs of Female Infertility
- Lack of or irregularities in the menstrual cycle.
- Increased bleeding during periods.
- Excessive pain during menstruation
- Signs of hormonal imbalances such as excessive hair growth, acne, weight gain.
- Lack of arousal.
Proper medical history along with family history, surgical history, lifestyle practices and other related details are very important to diagnose infertility.
Following this a thorough physical examination- of the external genitalia along with the breasts for women and prostate for men is mandatory.
Lab Diagnosis Of Infertility
- Routine blood tests are done to look for infections, tumor markers, and other indicators.
- Hormone panels are run for both men and women- using blood and urine samples.
- The levels of FSH and LH, along with progesterone in women and testosterone levels in men are examined.
- In Women, the hormone levels are indicated against the menstrual cycle to look for ovulation.
- Thyroid levels and other pituitary hormones are also tested for.
- Ultrasound imaging of the pelvic area help in the diagnosis of tumors, cysts and any other abnormalities.
- Testicular/Endometrial Biopsy may be indicated in certain cases.
- Basal Body Temperature is recorded for a certain period(few months) in accordance with the menstrual cycle- using the principle that during the ovulation period the body temperature rises slightly.
- However, when this isn’t conclusive, a laparoscopic intervention maybe is done to look for scar tissue in the organs which can be removed during the procedure itself.
- Semen analysis plays a major role and every factor of the sperm is assessed including the size, shape, count, volume, and motility.
- Any blockage in the pathway is identified using a harmless dye injected that sometimes helps by removing the blockage.
Treatment Of Infertility
Let’s explore the options for treatment of Male and female infertility-
- The treatments available for infertility are plenty and mostly cause-based.
- The treatments for infertility work by treating the cause of infertility in the affected.
- In the case of the cause not being reversible or primary infertility, the couple is presented with other options that shall help them have a baby.
Let’s explore each cause that was mentioned in the previous article and see how the treatment is done for each of the reversible causes.
- Correction of the hormonal imbalance and obesity. This is effective through a regimen that gives equal importance to proper medication as well as a strict diet and exercise that defines a healthy lifestyle. Only if the weight is under check and the person is of normal BMI, the medicines shall have their full effect. Once the hormonal imbalances are corrected, this may regulate the periods once again- the woman shall have a healthy menstrual cycle and her fertility shall definitely be improved. But the weight loss should be periodic and mustn’t be sporadic.
- Obstructions and tumors can be removed by surgeries as well as scar tissues, fibroids and polyps that are causing infertility. In males, surgery can be also used to descend the undescended testicles.
- Consumption of alcohol and abuse of drugs should be stopped effectively if the woman wants to get pregnant. The woman must also keep in mind that alcohol and drugs not only affect the chances of getting pregnant but in case pregnancy is achieved they cause fetal malformations in the baby that shall be long-lasting. Not to mention the other effects of these substances on the general health of the person.
Despite all the efforts to correct infertility if the couple is still unable to get pregnant, then a methodology called Assisted Reproductive Technology (ART) is known to be highly effective.
Assisted Reproductive Technology
Under the category of ART fall several methods that shall assist a woman in getting pregnant depending on the cause of her infertility. The general idea of ART is to make sure that the sperm and ova are both healthy and present in a favorable environment that results in their healthy fusion thus fertilizing the ova.
Following are types of ART that are widely used-
In vitro Fertilisation (IVF)
In this method, a Petri dish is used to allow fusion of the sperm and ova that are collected priorly from the parents or donors. Following fertilization, a selection of these zygotes are implanted into the uterus of the mother where they develop and grow as per gestational age.
Intra Cytoplasmic Sperm Injection (ICSI)
In this method, a single sperm is injected into an oval so as to fertilize it directly and this is then placed directly in the woman’s uterus. This is useful when the sperm has motility issues.
Gamete intrafallopian transfer (GIFT)
Gamete Intrafallopian Transfer and Zygote Intrafallopian Transfer are also popular methods. In GIFT the eggs collected are placed in a narrow tube with the sperm and injected into the Fallopian tubes so they get fertilized. In ZIFT the same method is used but following IVF so they can directly go to the uterus and be implanted.
In case of problems with the males, Artificial Insemination is a popular technique used to inject the sperm into the woman’s body while she’s ovulating so that it’s effective.
Other Solution for Infertile Couples
ADOPTION– This has a moral significance besides other factors and is a relatively popular method among many childless couples.
SURROGACY– A procedure where a woman who is not a part of the couple is made to carry the fertile eggs following IVF.
The child belongs to the parents whose egg and sperm are used legally.
SPERM/EGG DONORS- can either be combined with other methods of ART or can be used via artificial insemination.
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