Infertility

Infertility is a condition where a woman fails to conceive within one year of having regular unprotected sex. In healthy young couples who have regular sex, the woman has a 20% per month chance of getting pregnant every month. In about 85% of the cases, the woman will be pregnant within one year of trying. The chances are higher during the initial months.

Infertility affects 15% of couples attempting to conceive. About a third of the time, it can be traced to the woman. In another third of the case, it is because of the man. The rest of the cases are due to issues with both partners, or where there is no known cause. 

There are two types of infertility :

1. Primary infertility: It refers to couples where the woman is not pregnant after at least one year of having unprotected sex
2. Secondary infertility: In this case, the woman was pregnant at least once earlier, but is now unable to conceive.

Reproductive process

The testicles of the man produce sperms under the influence of hormones from the brain. These sperms mix with the secretions from the seminal glands and prostate to form the semen. It gets deposited in the vagina of the woman during sex. The sperms then travel up the uterus through the cervical canal to the fallopian tubes in the woman. There, it fuses with the oocyte or the egg. For this system to work, many factors have to play their roles properly. These include genes, hormones, and also mental and emotional factors. 

Causes of infertility in male 

The main causes of male infertility are due to the defects in:   

1. Production of sperms. It can be due to hormonal issues, genetic factors, undescended testes, etc.

2. Quality of sperm-Conditions like diabetes, varicocele, infections, and factors like medications, smoking, alcohol can all affect the quality.

3. Movement of sperms- genetic or structural problems, infections, injury can all affect this.

It is possible to identify and correct some of these problems. The purpose of the male evaluation is to identify these problems and treat them where possible.

Diagnosis of Male Infertility

Your doctor will ask for the medical history, physical exam, and semen analysis. The semen analysis checks the semen volume, sperm number, ability to move, and the quality of sperm. You may need to go for hormonal tests, genetic tests, ultrasound, and advanced sperm function tests in some cases.

The normal semen parameters are

• A volume in the range of 1.5 ml
• A sperm count in the range of 39 million 
• Progressive motility in the range of 32 % and total motility in the range of 40%

Treatment of male infertility

Your treatment will depend on the cause. Lifestyle changes can also play a key role in improving semen quality. Medicines may help improve problems in the quality and count of the sperm and also in treating infections. In males with low hormonal values, hormone replacement treatment is an option. You may need surgery in the cases of varicocele or similar conditions.

Causes of infertility in women 

A proper brain -ovarian axis is vital for normal female reproduction. Hormones from the brain (FSH and LH) acts on the ovary of the woman. Every month, a cohort of follicles get recruited from each ovary under the influence of these hormones. From this, a single dominant follicle grows and gets released as part of ovulation. The released ovum moves into the fallopian tube where it meets the sperm from the man. It is at this time that the fertilization happens. The egg can survive only for 24 hours, and so the sperms have to reach in that time.

The main causes of female infertility are

• Age: There is a decline in the quantity and quality of the eggs as you grow older
• Problems with ovulation: It can be PCOS (Polycystic ovarian syndrome), hormone issues, and premature ovarian failure.
• Issues with oocyte pickup and transportation: It can be due to endometriosis, pelvic adhesion, and tubal block. Due to the blocks, the eggs cannot move through the tube.
• Uterine fibroids and polyps: These are small growths that occur in the lining of the uterus

Diagnosis of Female Infertility

Your doctor will check with you about your medical history. They will ask for tests that help to identify problems with the uterus, fallopian tube, ovaries, etc. It includes

• Ovarian reserve test (AMH) helps in assessing the ovarian reserve.
• Ultrasound scans -will also help to detect problems in the uterus, assess ovulation and ovarian reserve.
• Hysterosalpingography (HSG) - HSG uses ultrasound or x-rays to check for any blocks in the fallopian tubes. 

Treatment of Female Infertility

Your doctor will advise the treatment depending on the cause. If you have problems with ovulation, your doctor will give drugs that help to set it right. These drugs help to stimulate your ovaries and release eggs. Lifestyle changes, like weight reduction, can also help in some cases.             

Medicines can also help with hormonal issues like thyroid problems. 

HLS procedure helps to remove blocks in the tube, fibroids, polyps, or adhesions. 

Assisted reproductive treatments (ART)

When routine treatments fail, or in few cases even as the first step, the couple will have to resort to ART to achieve a pregnancy. It includes fertility treatments that handle both egg and sperm. The common procedures are

1.Intrauterine Insemination (IUI):

In this, the treatment team will collect the sperms from the man as a first step. These are then washed and processed. The next step is to place the sperms directly inside the uterus of the woman. It increases the chances for the sperm and egg to meet and fertilize. The goal of IUI is to increase the number of good quality sperms that reach the fallopian tubes.

IUI may be an option if

• The cause of infertility is not clear
• The man has slightly low sperm count or decreased motility
• Sexual problems

2.In Vitro Fertilisation (IVF)

In this procedure, the sperm and egg are allowed to fuse outside your body. 

After the fusion of the sperm and egg, the doctor will deposit it in the uterus after 2 -5 days.

You will need IVF if you have 

• tubal block
• advanced endometriosis
• IUI failure
• Ovulation problems

3.Intra Cytoplasmic Sperm Injection (ICSI)

ICSI is an advanced type of IVF. In ICSI, the matured oocytes collected from the female partner gets injected with selected sperms. It is helpful for those who are not lucky with other types of IVF.

A more advanced form of ICSI is IMSI (intracytoplasmic morphologically selected sperm injection). Here the selection of sperms is done at a much higher magnification than in ICSI. It is useful in couples with repeated ICSI failure or recurrent pregnancy loss.

4.Preimplantation genetic testing (PGT)

It helps in identifying embryos that are not affected by a faulty gene. These embryos can result in abnormal offspring or failed pregnancy.

5.Donor Conception

Conception is possible by using sperms or oocytes from anonymous donors. It is a legally accepted treatment. Both the partners will need to give consent for this.

6.Surrogacy

It is an arrangement with a legal agreement. In this, a woman will carry and care for the child till birth for another couple, who will become the child’s parents after birth. There are laws in some countries like India that prevent foreign nationals from using this method.

Infertility remains a major clinical and social problem even now. People suffer from depression, shame, guilt, solitude, and social distancing due to this. The key to infertility management is not to go with set protocols, but to follow a systematic approach with empathy to the affected couple