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Infertility cause, treatment, diagnosis and risks

All you need to know about infertility

Infertility: Cause, Symptoms, Risks, and Treatment

The World Health Organization (WHO) defines infertility as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse

Overview


The World Health Organization (WHO) defines infertility as a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. If you and your partner are facing problems having a baby don’t worry you are not alone. According to NCBI Infertility affects 15% couples worldwide accounting for 48.5 million couples. India accounts for nearly 27.5 million couples facing this problem.

Read in detail about the infertility statistics worldwide

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Symptoms


The primary symptom of infertility is not getting pregnant, while some people may show direct symptoms of infertility many would show no direct symptom of infertility until they try to conceive.

Women with infertility may experience irregular or absent menstrual periods, Painful sex (dyspareunia).

Men facing infertility may experience certain hormonal symptoms like changes in facial hair growth or in sexual functioning

When to see a doctor? 


In many cases, the problem requires no treatment and the couple may get pregnant without any help.

But you should consider consulting a doctor if you and your partner have been trying to get pregnant for more than one year of unprotected sex.

Women should consult doctors early if they

  • Are of age 35 or above and have been trying to conceive for more than 6 months of unprotected intercourse  
  • Are 40 years or above 
  • Facing irregular, absent or painful menstrual cycle 
  •  Have been reported with endometriosis or pelvic inflammatory disease
  • Had multiple miscarriages
  • Have gone cancer treatment 

Men should consult a doctor

  • If they have had a history of testicular, prostate cancer
  • Small testicles or swelling in the scrotum 
  •  History of infertility in the family 
  • Undergone cancer treatment 

Causes of Infertility


Infertility problems in a couple may be due to one or both partners. According to the U.S. Department of Health & Human Services (HHS)

  • In1/3rd cases, There’s an issue with the man 
  • In 1/3rd cases, There’s an issue with the woman
  • In remaining cases there’s an issue with both partners or the issue can not be identified 

Cause of infertility in male

  • Abnormal sperm production or functioning which includes

    Absence of sperm in the semen (Azoospermia)
    reduced the number of sperm in the semen (Oligospermia),
    abnormal morphology (Teratospermia)
    or a high level of white blood cells in sperm (Leucospermia).

    All this could be due to genetic disorder, undescended testicles, health issues like diabetes or infections such as chlamydia, gonorrhea, mumps or HIV.

    Varicocele
    is the inflammation of the veins in testis which can affect the quality of sperm.

    Read about how to increase sperm count

  • Issues with the delivery of the sperm due to problems like premature ejaculation, a genetic disorder like cystic fibrosis and structural problems like a blockage in the testicle or damage in the reproductive organ.

  • Lifestyle-related issues like overexposure to certain environmental factors like

    pesticides and  radiation, Alcohol, Cigarette smoking, steroids, marijuana, high blood pressure, and depression

    can affect fertility  and overheat of testicles can affect sperm production (This could be due to frequent use of hot tubs and saunas)

  • Cancer treatment includes radiation and chemotherapy which can alter and damage sperm production and quality.

  • Obesity research shows that it has a negative impact on the sperm production and quality of the sperm 

Cause of infertility in female


Causes of infertility in women can be categorized under 4 broad categories based on the problems in a specific phase of the egg cycle

  • Ovulation Disorder (Release of the egg): 25% of the cases of infertility are due to ovulation disorders which arise due to reproductive hormones associated with the hypothalamus or the pituitary gland, problems with the ovary.

    • Polycystic ovary syndrome (PCOS): The cause of PCOS is not known but it’s associated with hormonal imbalance which causes enlarged ovaries with small cysts on the outer edges.

      PCOS is associated with obesity abnormal facial hair growth in females and insulin resistance in the body

      Read about PCOS in details

    • Hypothalamic dysfunction: FSH and LH are two key hormones produced by the pituitary gland that stimulates ovulation every month.

      Mental and physical stress, substantial weight gain or weight loss can, obesity can result in a disruption in their production and cause irregular or absent periods 

    • Premature ovarian failure: or primary ovarian insufficiency in which the ovary does not produce eggs, and it also lowers estrogen production in women under the age of forty.

    • Excessive Prolactin: Prolactin is the hormone that produces milk in females to nurture their children but excessive prolactin can reduce estrogen production which is required for ovulation resulting in infertility.

  • Tubal Infertility (Damage or blockage in the fallopian tubes): Damaged fallopian tubes restrict the passage of sperms from getting to the egg or the passage or fertilized egg towards the uterus. The main cause of tubal blockage or damage is

    • Pelvic Inflammatory Disease, caused due to infection from STDs like   chlamydia and gonorrhea 

    • Abdominal surgeries like ectopic pregnancy, in which the fertilized egg implants in a fallopian tube.

    • Pelvic Tuberculosis

  • Endometriosis (Problems in the layer implantation of the egg): endometrium is the tissue that lines the inside of a woman’s uterus. In endometriosis this tissue implants and grows in other locations.

    This extra tissue growth (and it’s surgical removal) may cause scarring, which blocks the fallopian tube and stops the union of the sperm and egg.

    It may also cause difficulties in the implantation of the fertilized egg. The exact cause of endometriosis is not known.

  • Uterine and cervical causes (problems in the implantation of the fertilized egg):

    • Benign Tumors (Fibroids) are common in the uterus. Some can interfere with the implantation process which causes infertility. But, many women who have fibroids do get pregnant 

    • Abnormally shaped uterus can lead to difficulty in getting or in some cases remaining pregnant. These abnormalities are present from birth.

    • Cervical stenosis is the narrowing of the cervix. Cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus. This problem can be hereditary or may arise due to damage to the cervix

    • Endometriosis can prevent implantation of the egg in the uterus.

    • The mucus produced in the cervix can prohibit the sperm to travel to the cervix and reach the uterus.

Unexplained Infertility

Sometimes the cause of infertility can not be pinpointed. It may arise due to several minor factors in both partners that add up to cause infertility. Not knowing the cause of infertility can get pretty frustrating but it may correct itself with time.

But, couples are advised not to delay the treatment of infertility.

Risk factors that can cause infertility

Risk factors that cause infertility can be the same for both the partners. They include 

  • Age: age and fertility are closely linked both for men and women. Fertility in women starts to decline in their mid 30’s and starts to rapidly decline after the age of 37 due to several reasons like a decrease in the quality and number of eggs in the ovaries. Men above 40 years of age are less fertile than younger men.

    Read in detail about Age and Fertility

  • Alcohol Consumption: For women, If you are trying to conceive there is no safe amount of alcohol that you can consume.

    For men, excessive consumption of alcohol can decrease the sperm count and mobility of the sperm 

  • Tobacco Consumption: Smoking can reduce the chances of pregnancy. It can also decrease the success rate of fertility treatment due to consumption by either partner.

    According to a Reuters report, women who smoke tend to have more miscarriages than non-smokers. Men who smoke increase the risk of erectile dysfunction and low sperm count.

  • Being obese or overweight: being obese and overweight can lead to infertility and can also be indicative of PCOS. In men, it can affect the sperm count.

  • Being underweight: underweighted may be associated with eating disorders like bulimia or anorexia, It can also indicate a restricted and a low calories diet which puts women at risk of infertility.

  • Exercise: lack of exercise contributes to overweightness and obesity which is alarming. Strenuous exercise in some cases can lead to ovulation problems

  • STDs: gonorrhea and chlamydia can lead to pelvic inflammatory diseases in women and can also lead to epididymis blockages leading to infertility in men.

  • Mental health: issues like stress and depression disrupt the hormones that regulate the reproductive cycle that cause an irregular menstrual cycle in women and low sperm count in men.

  • Environmental factors: you may lower the chance of getting pregnant due to exposure to certain radiation and toxicity in your work environments like toxic metals, pesticides, and radiation.

    If you are undergoing cancer treatment through chemotherapy it may also lead to infertility.

  • Caffeine consumption: according to a report of NCBI less consumption of caffeine can increase the likelihood of pregnancy.

Prevention


Couples 


Couples are advised to have regular intercourse around the ovulation time to increase the chances of getting pregnant. Having intercourse 5 days prior to ovulation increase the likelihood of getting pregnant.

some other precaution should be to 

  • Quit smoking if you smoke and are considering getting pregnant you should quit now. 

  • Avoid drugs and alcohol, they can interfere with the pregnancy.

  • Men should avoid hot tubs and saunas as they can affect sperm production.

  • Avoid environmental toxins

  • Exercise moderately

  • Women should limit caffeine consumption

Tests and Diagnosis


Infertility can be treated but to treat it you must know the underlying problem. infertility treatment can be expensive so it’s really important to choose the right infertility doctor and clinic.

Many clinics and doctors may assure it but Infertility treatment does not have a guarantee of success.

Learn more about how to find the right fertility clinic 

Learn more about the cost of IVF

Tests for Men


All tests are primarily associated with sperm. The health of your sperm depends on sperm count, morphology and speed. Ideally, your sperm count should range from 15 million to more than 200 million sperm per milliliter of semen with 40% total motility and 4% good sperm morphology.

You may undergo a general physical exam including an examination of your genitals as well. Specific fertility tests for men may include

  • Semen Analysis: you may be asked for one or multiple samples by your doctor. This is usually done by masturbating. A lab analyzes your sperm.

  • Hormonal Exam: you may undergo a blood test to check the levels of testosterone and other male hormones. The normal range is 270-1070 ng/dL.

  • Testicular Biopsy: It can be done to detect abnormalities in the male genital to identify the underlying infertility problem.

  • Sperm Agglutination Test: it is used to determine if the sperms are clumping together which enables it to swim through the cervix mucus.

  • Urine Analysis: It can be done to check the presence of WBC in the urine which would point towards possible infection or presence of sperm in urine which would indicate a problem with ejaculation also known as retrograde ejaculation

  • Vasography: it’s used to determine if there is a blockage or leak of sperm vas deferens (A tube that carries sperm from testis to penis)

  • Ultrasonography: Any blockage in the reproductive tracts including prostate, seminal vesicles, and ejaculatory ducts can be identified with this test.

  • Genetic Test: It’s done to determine if there is any genetic defect causing infertility.

Tests for women

Fertility in women rely on several factors and determining the cause of infertility in women is more complex than that in males

You may undergo a general physical exam including a regular gynecology exam as well. Specific fertility tests for women may include:

  • Ovulation Test. Luteinizing Hormone(LH) is at its peak just before ovulation (This phenomenon is called LH surge) which is used to check whether you’re ovulating by a blood/urine test 

  • Sonohysterography: This test uses ultrasound to detect intrauterine problems like tumors, polyps, and fibroids after filling the uterus with a saline solution that improves detection.

    If an abnormality is observed, a hysteroscopy is typically done.

  • Hysterosalpingography. It is done to evaluate whether the fallopian tubes are open and the shape of the uterine cavity is normal using X-ray. X-ray contrast (Liquid containing iodine) is injected into your uterus through a catheter.

    The liquid fills the uterus and enters the tube outlining the lengths of the tube and any abnormality in the shape.

  • Ovarian Reserve Test. This test helps in determining the quantity of the eggs available for ovulation, whether the women can produce an egg of good quality.

    The ovarian reserve test is commonly an FSH blood test drawn on the 3rd day of the menstrual cycle. This test is very important for women of age more than 35

  • Other hormonal Tests. Other hormone tests determine levels of ovulatory hormones, as well as pituitary hormones which include Thyroid Stimulating Hormone, Prolactin, DHEAS,17-α hydroxyprogesterone, and Testosterone 

  • Hysteroscopy. Depending on symptoms, doctors may recommend a hysteroscopy to look for uterine diseases. A light telescope-like instrument (Hysteroscope) is inserted in the uterus to check abnormalities

  •  Laparoscopy. It is a  minimally invasive surgery that involves making a small surgical cut in the navel and a light telescope-like instrument (laparoscope) is inserted in the pelvic cavity to examine fallopian tubes, ovaries, and uterus.


    A laparoscopy identifies endometriosis, blockages, scarring, and other irregularities. It’s a costly procedure, therefore, a series of other tests are recommended prior to undergoing a laparoscopy

It is important to note that every case of infertility is unique so the infertility evaluation should always be individualized. One may not require all the tests listed above therefore it’s really important to choose the right doctor and fertility clinic.

Treatment


Infertility is treatable but not always. The treatment depends on the underlying cause that causes infertility and

  • The age of both the partners
  • How long has the fertility problem existed
  • Your preference for treatment


Even in the case that infertility can not be treated couples can always go for Assisted Reproductive Technology (ART) or adoption, But it’s really important to note that the assisted reproductive technology can be really costly, time-consuming, stressful and does not guarantee a pregnancy.

If you plan on getting any fertility treatment you should avoid consumption of tobacco and alcohol as they lower the success rate of the treatments  

Treatment for men

Treatments for men may involve

  • Counseling and Medication to treat any problems that may exist with erection and ejaculation

  • Hormone Therapy to counter and ups and downs in certain hormones (like testosterone)

  • Antibiotics may be used to treat any reproductive infections and diseases

  • Surgery to remove any tubal blockages that restrict the movement of sperm in the genital organ or in the case of varicocele which widens the veins in the scrotum.


Treatment for women


Treatments for women may involve

  • Fertility Drugs helps women in ovulation and in restoring and disruptions in the hormone level. These drugs primarily stimulate hypothalamus and pituitary to release GnRH, FSH and LH hormone which triggers ovulation in women

  • Surgery is done to remove tissues or blockages that cause infertility in women. Hysteroscopic and Laparoscopic surgeries are performed to remove small and large fibroids, polyps, endometriosis, and pelvic adhesions.

  • Injectable hormones may be prescribed to stimulate ovulation, Several different kinds of hormonal preparations are available that help you counter infertility

Assisted Reproductive Technology(ART)


Assisted reproductive technologies are fertility treatments that involve the handling of sperm and egg. We will briefly cover all the widely known ARTs in this section.

  • In Vitro Fertilization (IVF) commonly called “test-tube baby” is one of the most commonly used fertility ART.

    IVF involves fertilization or mating or the egg and sperm outside the body in a dish under a controlled lab environment. Once the sperms are fertilized the embryo is transferred and implanted in the uterus of the female partner.


    Know in detail about IVF |Process|Success Rate|Cost

  • Intrauterine insemination (IUI) is a technique in which sperms are placed in the uterus around the time of ovulation to facilitate fertilization.

    The primary goal is to increase the number of sperms to reach the fallopian tube which might have been hindered otherwise due to tubal blockages or low sperm motility.

    Based upon the location of transfer it can also be called as Gamete Intrafallopian Tube Transfer (GIFT)

  • Intracytoplasmic sperm injection (ICSI), In a healthy male-only about 40% of the sperm are motile and not even all of these are able to reach the egg.

    If a person has a low sperm count this problem becomes even more Sevier. In ICSI a single healthy sperm is injected directly into a mature egg to increase the chances of fertilization

  • Donor eggs or sperm are used in the case there are multiple problems with eggs or sperm of the couples. The donors can be anonymous or someone you know.

  • Assisted Hatching is an ART performed when there is a problem with the implantation of the embryo on the uterus.

    The technique involves the removal of the outer layer of the embryo to assist in the implantation (or hatching) of the embryo on the wall of the uterus.

  • Surrogacy. When the uterus of the female partner is not functional or can not bear a child the embryo is implanted in the uterus of a donor (Surrogate) who carries the embryo through the entire pregnancy.


    laws regarding surrogacy vary from country to country but in most countries like India, altruistic surrogacy (that involves no financial transactions between the couple and the surrogate apart from the medical bills) is legal.

Complications of treatment


There can be a few complications of fertility treatments like

  • Multiple and Premature Pregnancies: Many times the fertility treatments lead to multiple pregnancies-Twin, Triplets or sometimes more due to which there are more chances of premature delivery or labor.

    Premature deliveries may experience developmental issues. Not to mention the financial responsibility that increases due to multiple births.

  • Bleeding or infection: with any surgical procedure there usually is a risk of infection and bleeding in the reproductive organ.

  • Ovarian hyperstimulation syndrome (OHSS). Fertility drugs induce ovulation which can cause OHSS, in which the ovaries become swollen and painful. Symptoms can include abdominal pain, nausea, irritation that may last for about a week.

It’s going to be an emotional journey


Infertility and its treatment can be an emotional rollercoaster for the couple. It’s really important for couples to look out for each other and themselves.

The key is to never lose hope, There have been cases where fertility treatment do not give any results for a long time but you should always discuss this with your doctor and always have realistic expectations. The more you will discuss this with your partner, friends, and family the better it will be for you.

It’s everyone’s personal choice to decide for themselves but always remember that adoption is always a choice.

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