Infertility and its treatment

What is Infertility?

Infertility is a condition in which a person cannot reproduce by natural means after 12 months (or longer) of regular unprotected sex. 15% of couples all over the world are infertile, which is equal to 48.5 million couples.

What are the symptoms of infertility?

Not getting pregnant is the main symptom of infertility. Besides this, there may not be any other obvious symptom. However, some other possible symptoms might include:

Women: irregular or absent menstrual periods.
Men: hormonal problems or changes in hair growth or sexual function.

When should you see a doctor?

Single or multiple issues cause infertility in you or your partner, thereby preventing pregnancy.

Unless you have been trying to get pregnant regularly for at least a year, you don't need to see a doctor. As a woman might need to consult with a doctor if your answer to the following questions is a “Yes”:

Is your age is greater than 35 and you have been trying to conceive for 6 months or more?
Is your age is more than 40?
Do you have painful periods?
Have you had multiple miscarriages in the past?
Have you undergone treatment for cancer?
Do you have known fertility problems?
Have you been diagnosed with endometriosis or pelvic inflammatory disease?
Do you have irregular or absent periods?

What are the causes of infertility?

For a successful pregnancy, everything during ovulation and fertilization should happen correctly. Occasionally the factors causing infertility may be present since birth, or it may develop later in life.

The causes of infertility can affect one or both partners. Generally:

One-third cases: problems with the man
One-third cases: problems with the woman
Remaining cases: no problems found with either man or woman

What are the causes of male infertility?

Poor Sperm Quality: Following are some of the factors that could lead to abnormal sperm function:
- Undescended testicles
- Genetic defects
- Health problems like Diabetes
- Bacterial infections in semen

Sperm Delivery: Following are some of the factors that cause abnormalities in sperm delivery:
- Sexual problems, for example, premature ejaculation.
- Genetic diseases, for example, cystic fibrosis.
- Structural problems, for example, blockage in the testicle.
- Injury, for example, damage to the reproductive organs.

Environmental factors: Overexposure to the following:
- Pesticides and other chemicals
- Radiation
- Cigarette smoking
- Alcohol
- Marijuana
- Anabolic Steroids
- Medications for bacterial infections
- High blood pressure
- Depression
- Frequent exposure to heat in places like, saunas, hot tubs – these raise body temperature considerably and affect sperm production
Cancer and its treatment: These can affect sperm production temporarily or permanently. Radiation therapy and chemotherapy can slow down or completely stop sperm production.

What are the causes of female infertility?

Endometriosis:
Damage or blockage in the fallopian tube
Disorders in ovulation:
Pelvic adhesions
Abnormalities in uterine or cervix
Cancer and its treatment

What can affect your fertility- Risk Factors

Some of the risk factors for men and women are the same:

Age: The fertility of a woman decreases with age. Noticeable drop in fertility for women starts in the mid-30s, whereas it declines rapidly after the age of 37.

Note: Infertility in older women is because of:

A lower number of eggs.
Lower quality of eggs.
Other age-related health problems.
Obesity: Inactive lifestyle and being overweight can increase the chances of infertility in men and women. Being overweight leads to lower sperm count in men.
Being underweight: There is a high risk of fertility problems among women who:
- have eating disorders like anorexia or bulimia
- follow a low-calorie or restrictive diet
Tobacco & Marijuana: If either of the partners smokes either tobacco or marijuana, then the likelihood of getting pregnant decreases. Smoking also decreases the chances of fertility treatments being effective.
- Women who smoke are more prone to miscarriages.
- Men who smoke have a higher chance of suffering from erectile dysfunction or low sperm count.
Alcohol: This can lead to infertility.
- Men: heavy alcohol can decrease:
  - Sperm count
  - Sperm motility
- Women: There is no safe alcohol usage limit during
  - Conception or
  - Pregnancy
- Exercise: Physical activity does affect your fertility:
  - Lack of exercise: leads to obesity, which in turn increases the chances of fertility.
  - Too much exercise: can lead to:
    - Ovulation problems in women who are not overweight
    - Reduces testosterone level in men, thereby decreasing the sperm count.

How can we prevent infertility?

Some types of infertility are beyond prevention. However, you can follow certain practices in your daily life to increase the chances of pregnancy:

Men: Even though male infertility is unavoidable, the following steps may help:

Exercise regularly: This can improve sperm quality.
Avoid drugs, tobacco and excessive alcohol: as these may lead to infertility.
Avoid medications that negatively affect fertility: These can include both prescription and non-prescription drugs.

Alert: While it is not advisable to stop your medications, it is advisable to discuss the side effects of any medicines you regularly take.

Avoid high temperatures in hot tubs and hot baths: as continuous and regular exposure to high temperatures may decrease:
- Sperm production
- Sperm motility
Avoid exposure to toxins(industrial or environmental):these might affect sperm production.

Women: Following steps can significantly improve the chances of getting pregnant:

Regular moderate exercise: Regular exercise is vital for controlling weight and maintaining proper amounts of physical activity. However, doing intense exercise regularly can lead to infrequent or absent periods, which would negatively affect fertility.
Quit smoking: Tobacco has numerous adverse effects on fertility. It also affects your general health and the health of a fetus. Smoking, in general, should be avoided; however, one must quit it during pregnancy.
Say no to drugs and alcohol: These may stop you from conceiving or having a healthy pregnancy. If you want to get pregnant, don’t abuse substances like marijuana or alcohol.
Avoid weight extremes: Being overweight or underweight can negatively affect hormone production, thereby leading to infertility.
Limit caffeine usage: Consult your doctor to know about safe caffeine limits if you are trying to get pregnant.

How is infertility treated?

Some of the medications that can help in the treatment of infertility include:

Clomiphene citrate: This drug acts on the pituitary gland of the brain and causes ovulation. Doctors recommend these to women who suffer from polycystic ovarian syndrome (PCOS). You have to take it orally.

Human menopausal gonadotropin: Some women have problems ovulating due to issues in their pituitary glands. hMG is injected to stimulate the development of eggs by working on the ovaries.

Gonadotropin-releasing hormone analogs: Also known as Gn-RH –when injected,these cause the pituitary gland to change when the body ovulates. In a few cases, they help with ovulation, whereas in some of the other games, they help in suppressing ovulation.
Follicle-stimulating hormone: Also known as FSH, it has similar working like hMG and is usually injected. It induces the egg development process in the ovaries.

Metformin: Healthcare providers recommend these to women who have:
- low insulin, and/or
- PCOS

Metformin sensitizes the body to insulin and helps the body in ovulating regularly. Occasionally a combination of metformin with either clomiphene citrate or FSH is administered. You have to take this medication orally. Sometimes, it leads to gastrointestinal side effects.

Bromocriptine: This is administered to women who have high levels of prolactin and therefore suffer from ovulation problems. Prolactin is a hormone that helps in milk production.

How is intrauterine insemination done?

This procedure is straight forward and will be carried out in your fertility clinic

The semen goes through a washing procedure that removes impurities from the semen. The washing is done because semen contains more than just sperm and only what's needed for conception is retained through the washing procedure.
After that, the sperm is put in the uterus via a catheter inserted through the cervix.
The timing of this procedure is kept as close as possible to the woman’s ovulation cycle (or the fertility medications)

What is assisted reproductive technology (ART):

The procedure where the harvested eggs of a woman are combined with sperm and the embryo produced is put back in the woman's uterus, which is called ART.

The success rate of ART depends on a woman’s age and prognosis.

Following are the two types of ART:

In vitro fertilization (IVF): This is the most effective form of ART. In it, the egg is fertilized with the sperm outside the body. Even though it is not the first form of treatment offered, it may be used in a variety of fertility conditions.

Step by step:

Women undergo one or two weeks of fertility injections. This causes the ovaries to generate multiple eggs at one time.
After the eggs mature, they are removed from the woman. The process of removing the eggs, is a short and a minimally invasive procedure. During the removal of eggs the woman is under the influence of anesthesia.
The eggs are combined with the man’s sperm for fertilization. This is done in a dish in an embryology lab.
The embryos are allowed to grow for 3 to 5 days in the lab.After this duration of 5 days, they are implanted in the woman's uterus.
The pregnancy test to check the success of the process is performed after two weeks.
Intracytoplasmic sperm injections (ICSI):This is recommended to couples who have problems with the sperm. In this procedure, a single sperm is injected into a mature egg. The embryo is then transferred to the uterus.

In ART procedures, occasionally, your healthcare providers will recommend the use of:

donor egg – if a woman:
- cannot produce eggs
- has low-quality eggs
- hasa genetic disease that can be passed on to the baby.
donor sperm – if man:
- has severe infertility
- has a genetic disease
previously frozen embryos or donor embryos-The donor embryos are referred to infertile woman or couple. These embryos are created either by:
- couples in infertility treatment, or;
- created from donor sperm and donor eggs.

The donated embryo is then transferred to the uterus and the child will not be genetically related to either parent.

Alternative infertility treatments

Gestational carriers are recommended to women:

With medical contraindications to pregnancy
Women who have uterine factor infertility

Procedure:

An embryo placed by a couple is placed inside the uterus of the gestational carrier
The gestational carrier carries then fetus to term
After the term, the couple that produced the embryo gets the baby

What risks and complications can arise as a result of infertility treatments?

Multiple pregnancies: Infertility treatments can often lead to multiple pregnancies (twins, triplets, or more).

Generally, as the number of fetuses increases, the risk of premature labor and delivery increases too. You should discuss with your healthcare provider about the possibility of multiple pregnancies after infertility treatment.

Solution: Fetal reduction (intentionally decreasing the number offetuses in a woman’s uterus) can help in delivering fewer babies with reduced health risks.

Bleeding or infection: Like any other invasive procedure, assisted reproductive technology does pose the risk of bleeding or infection.

Birth Defects:A few studies have concluded that the use of IVF may lead to an increased chance of specificcongenital disabilities (birth defects). However, a few studies indicate that the birth defect may be due to the underlying cause of infertility in couples and not necessarily due to the IVF procedures.
Low birth weight: Multiple fetus pregnancy generally leads to Low Birth Weight. However, single live births may also lead to preterm delivery or low birth weight if IVF has been used.
Ovarian hyperstimulation syndrome (OHSS): In this condition, the ovaries become swollen and painful. If injectable fertility drugs are used to induce egg development, then the chances of OHSS are likely. Symptoms of this syndrome include:
- Mild abdominal pain
- Bloating
- Nausea

Alert: A severe but rare form of OHSS could also lead to:

Rapid weight gain
Shortness of breath

If you notice these symptoms, immediately contact your health care provider as you may need emergency treatment.

How to increase the chances of pregnancy?

To increase the pregnancy rate, have regular intercourse multiple times during ovulation. Your chances of getting pregnant are high if you have intercourse in the duration beginning from five days before and a day after ovulation. Generally, ovulation usually occurs halfway between the menstrual cycle.

Reference:

Dr Purva Singh

MBBS MS OBGYN
IVF Specialist