An Overview of Infertility
An Overview of Infertility – A Guide For Patients
A couple is said to be infertile when they have not achieved a pregnancy after two years of having regular, unprotected intercourse. If you have been trying to conceive for more than one year you may need to have tests for infertility.
However, if you are in your 30s or older, you should begin the infertility tests after about six months of trying rather than a year, so as not to delay treatment
in this age group. Also, if you have very irregular menstrual cycles (suggesting that you are not ovulating), or if you or your partner has a known fertility problem, you probably should not wait an entire year before seeing a specialist for treatment. If you and your partner have been unable to have a baby, you’re not alone. One out of six couples has trouble conceiving. During this time, it is normal to experience feelings of frustration, jealousy and anger. However, once you begin to explore your medical options, you will find that fertility treatments offer more hope for a successful pregnancy than ever before.
The initial visit
Once you decide upon consultation, you and your partner will first be asked certain important questions by the doctor and your previous treatment records will be reviewed.
Both you and your partner should attend the first meeting together since infertility is a shared experience and is best dealt with as a couple.
During this visit, you will begin to understand the degree of commitment and cooperation that an infertility investigation is required.
In a typical initial visit, the physician will ask about:
The frequency and regularity of your menstrual period
Abdominal pain during periods
Abnormal vaginal bleeding
Vaginal discharge, history of pelvic infection
Previous pregnancies – if any
Methods of contraception used if any.
Your husband will be asked questions about:
Prior genital injury, operations or infections
Drug and/or medication usage
Previous children if any
Medical illnesses and treatment.
You’ll be asked how long you’ve been trying to conceive, how often you have sexual intercourse, if you use lubricants during intercourse, and if anyone in either family has birth defects. Your doctor will need to know the complete sexual and reproductive histories of you and your partner, including any former relationships.
Since at least 25% of infertile couples have more than one factor causing infertility, it is very important to check all factors that may affect both you and your partner.
During the first visit, you may discuss the emotional stress of infertility, a subject that is often difficult for you to share with family and friends. Doctors know that the procedures and intimate questions involved in an infertility work up can be difficult. You should always feel free to make your physician aware of your worries and frustrations.
THE PROCESS OF CONCEPTION
In order to understand the fertility tests and treatments you may be offered, it is important to understand how conception naturally occurs. First, your ovary must release an egg, which must be picked up by the fallopian tube. Sperm must travel through the vagina, into the uterus, and up into the fallopian tube in order to fertilize the egg. Fertilization usually takes place in the fallopian tube. Then, the fertilized egg, or embryo, travels down to the uterus, where it implants in the uterine lining and develops. Infertility results when a problem develops in any part of this process.
The Ovulation Factor
Egg production is the commonest cause of infertility, accounting for approximately 25% of all infertility cases. Ovulation involves the release of a mature egg from one of your ovaries. After ovulation, the ovary produces the hormone progesterone. During the 12 to 16 days before the onset of your period, progesterone changes the lining of your uterus into a favourable environment for implantation and nurturing of the fertilized egg.
If you have regular menstrual cycles, you are probably ovulating. Cycle lengths of approximately 24 to 34 days are usually ovulatory. If you only have a period every few months or not at all, you are probably not ovulating or are ovulating infrequently.
We usually test your hormone levels on day 2 or 3 to see if your ovaries are working well and some other hormone tests ( thyroid, prolactin)
Anovulation can be treated by tablets or injections called gonadotrophins.
The Tubal Factor
Because open and normally working fallopian tubes are necessary for conception, tests to determine tubal openness (patency) are important. Tubal factors, as well as factors affecting the peritoneum (lining of the pelvis and abdomen), account for about 35% of all infertility problems.
A special x-ray called a hysterosalpingogram (HSG) can be performed to check the fallopian tubes and uterus. During a HSG, a special fluid (dye) is injected through your cervix, fills your uterus, and travels into your fallopian tubes. If the fluid spills out through the ends of the tubes, they are open. If the fluid does not spill out, then the tubes are blocked.
If the HSG shows blocked fallopian tubes, your doctor may perform a laparoscopy to assess the degree of tubal damage. If the tubes are found to be blocked, scarred, or damaged, surgery can sometimes correct the problem. Although some tubal problems are correctable by surgery, women with severely damaged tubes are so unlikely to become pregnant that in vitro fertilization (IVF) offers them the best hope for a successful pregnancy. Because very badly damaged tubes may be filled with toxic fluid (hydrosalpinx) and are known to lower IVF success rates, your doctor may advise removal of the tubes prior to IVF. More information on tubal disease can be found in the patient Information booklet titled Tubal Factor Infertility.
The Male Factor
In approximately 40% of infertile couples, the male partner is either the only or an additional cause of infertility. Therefore, a semen analysis is important in the initial evaluation. To prepare for a semen analysis, your partner will be asked to avoid having intercourse for at least 48 hours. He then will collect a semen sample in a cup by masturbating in a special room in the hospital. In some cases, a semen sample may be obtained during sexual intercourse using a special condom. The semen specimen is examined under a microscope to determine the volume (amount), motility (movement), and morphology (appearance and shape) of the sperm. In general, two or three semen analyses are recommended over two to six months, since sperm quality can vary over time. Other tests may be recommended as well. Treatment for male factor infertility may include antibiotic therapy for infection,surgical correction of varicocele (dilated or varicose veins in the scrotum) or duct obstruction, or medications to improve sperm production. In the majority of cases, no obvious cause of poor sperm quality can be found.
Intrauterine insemination (IUI) or IVF may then be advised. Direct injection of a single sperm intoan egg (intracytoplasmic sperm injection [ICSI]) may be recommended as well.
If no sperm are present, your doctor may discuss using a sperm donor.
Insemination with donor sperm may also be considered if IUI is not successful or if you and your partner do not choose to undergo IVF.
Even if no sperms are present in the semen, we may be able to obtain sperms from the testes by a process called – TESE (Testicular sperm extraction).
The Age Factor
Delaying pregnancy is a common choice for women in today’s society. The number of women in their late 30s and 40s attempting pregnancy and having babies has increased in recent years. If you’ve chosen to delay pregnancy, due to college or career for example, you may not realize that your fertility begins to decline significantly in your mid 30s and accelerates in your late 30s. Some women even begin to experience a decline in their fertility in their late 20s and early 30s.
Fertility declines with age because fewer eggs remain in your ovaries, and the quality of the eggs remaining is lower than when you were younger. Blood tests are now available to determine your ovarian reserve, which reflects your age related fertility potential. In the simplest of these tests, the hormones FSH and estradiol are tested in your blood on the second, third, or fourth day of your menstrual period. An elevated FSH level indicates that your chances for pregnancy may be slim, especially if you are age 35 or older, but does not mean that you have no chance of successful conception.
Older women tend to have a lower response to fertility drugs and have a higher miscarriage rate than younger women. The chance of having a chromosomally abnormal embryo, such as one with Down syndrome, also increases with age. Because of the marked effect of age on pregnancy and birth rates, it is common for older couples to begin fertility treatment sooner and, in some cases, to consider more aggressive treatment than younger couples.
Possible treatments for age-related infertility in women include fertility drugs plus IUI or IVF. In cases where the treatments fail or are predicted to have a low chance of success, egg donation is an option. Egg donation has a high chance of success, regardless of your FSH level. For couples who have not succeeded with fertility treatments or who choose to forgo treatment, adoption is an important option.
The Uterine Factor
The hollow space inside your uterus where an embryo would implant and develop is the uterine cavity. The uterine cavity needs to be smooth for the embryo to implant and grow normally. Possible uterine abnormalities that may be identified include adhesions or uterine scar tissue, polyps (bunched-up pieces of the endometrial lining), tumours called fibroids, or an abnormally shaped uterine cavity.
Problems within your uterus may interfere with implantation of the embryo or may increase the incidence of miscarriage.
There are three tests to determine if the cavity is normal. Saline sonogram
An SSG is a pelvic ultrasound performed while saline is injected through your cervix to outline the uterine cavity. Hysterosalpingogram can also be used to outline the cavity. The best test is a hysteroscopy which means introducing a camera (hysteroscope) into the cavity of the uterus through the cervix and directly visualizing it.
Peritoneal Factor Infertility
Peritoneal factor infertility refers to abnormalities involving the peritoneumsuch as scar tissue (adhesions) or endometriosis. Endometriosis is a condition where tissue that normally lines the uterus begins to grow outside the uterus. This tissue may grow on any structure within the pelvis including the ovaries and is found in about 35% of infertile women who have no other diagnosable infertility problem. Endometriosis is found more commonly in women with infertility. For further information concerning this problem, see the Jananam booklet titled Endometriosis.
Laparoscopy is a surgical procedure which is performed to diagnosis and treat adhesions or endometriosis. Laparoscopy is usually performed under general anesthesia, often in a hospital’s same-day surgery unit. During the procedure, a narrow, lighted telescopic instrument called a laparoscope is inserted through a small incision within or just below your navel.
The doctor can then look directly into your abdominal cavity and see the ovaries, fallopian tubes, and uterus. A dye is usually injected through the cervix to determine if the passage to the uterus and tubes is open. One or more additional smaller cuts may be made above your pubic area in order for your doctor to insert additional instruments if required and treat any disease if found. This procedure is not routinely performed in an infertility evaluation. Laparoscopy is expensive and involves some surgical risk. Your doctor will discuss whether or not laparoscopy is needed in your particular case.
In approximately 5% to 10% of couples trying to conceive, all of the above tests are normal and there is no apparent cause for infertility. In a much higher percentage of couples, only minor abnormalities are found that are not severe enough to result in infertility. In these cases, the infertility is referred to as unexplained. Couples with unexplained infertility may have problems with egg quality, tubal function, or sperm function that are difficult to diagnose and/or treat. Fertility drugs and IUI have been used in couples with unexplained infertility with some success. If no pregnancy occurs within three to six treatment cycles, IVF may be recommended.
CHANCES OF SUCCESS WITH IVF
Each couple has a unique set of circumstances, and the chances of treatment success vary widely. The success of IVF depends on many factors, especially your age. The younger you are the better the chance of pregnancy. Also a couple who has a single factor has a better outcome after IVF. Pregnancy will depend on the quality of the eggs, sperms and also on the grade of the embryos formed. Your doctor will be able to discuss the details with you in further detail.
Infertility is a medical condition that has many emotional aspects. Feelings such as anger, sadness, guilt, and anxiety are common and may affect your self esteem and self-image. You may find it difficult to share your feelings with family and friends, which can lead to isolation. It is important to know that these feelings are normal responses to infertility and are experienced by many couples. Your doctor will describe various treatments and explain the chances of success with treatments. It is important for you both as a couple to make an early decision regarding the best treatment option. Remember always that age is a vital determinant of success and the earlier the better.
For any queries do not hesitate to ask our team. They are always ready to support, explain and guide you wholeheartedly.
Thanks to the many options existing today, including advanced reproductive technologies and adoption, most infertile couples will be able to experience the joy of parenthood
Dr. Vani Sundarapandian
Medical Director, Jananam Fertility Center