Next to the instinct for survival, the urge to procreate is strongest in all living beings. Though most people fulfill this desire to reproduce and raise offspring there are an unfortunate few that are unable to do so. Such couples suffer from great emotional stress, more so because of the social stigma attached to infertility. It is important not to lose heart, for rapid progress had been made in this branch of science, and medical aid is available to most of infertile couples.
Infertility Definition. What Is Infertility ?
- The couple has not conceived after 12 months of contraceptive-free regular intercourse if the female is under the age of 34.
- The couple has not conceived after six months of contraceptive-free intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy).
- The female is incapable of carrying a pregnancy to term. Infertility can be further divided into primary and secondary. Couples with primary infertility have never been able to conceive while, those with secondary infertility have difficulty in conceiving after already having conceived before, irrespective of whether the previous pregnancy had ended in a delivery or a miscarriage.
Some people with conditions like endometrisis, polycystic ovarian disease are sub-fertile which means that they have lower chances of conceiving than an average couple.
About 15 per cent of all married couples are infertile. Of these about a third are due to female causes, another third due to male causes and in the remaining third both partners have problems that make them incapable of having a child. Due to various reasons like increasing age of marriage, planned delay in conception, and environmental factors, the number of infertile couples have been increasing worldwide.
Causes Of Infertility And Process Of Conception
To understand the causes of infertility it is important to understand the process of conception. The internal female genitalia comprises two ovaries that are responsible for the production of female hormones and eggs (ova). There is a uterus in a pyriform structure of about 3” x 2” x 1” with a fallopian tube attached on either side. The vagina connects the uterus with the external genitalia. The vagina is the organ for intercourse, the receptacle for semen, and forms the birth canal during delivery. A single egg is released during each menstrual cycle usually around the 14th day before the next period is due – this works out to be mid-cycle in women with a normal, 28-day cycle. One must remember to count the first day of the period as day one. The egg is picked up by the finger like processes at the loose end of each tube called fimbria and is transported towards the uterus. If intercourse occurs during this fertile period the sperms swim up and fertilize the ovum in the proximal part of the tube. The fertilized egg is transferred to the uterus where it gets attached to the uterine wall and remains lodged there for the nine months of pregnancy.
What Causes Infertility
Infertility may be due to a single cause in either the woman or her partner, or a combination of factors that may prevent a pregnancy from occurring or continuing till term.
Common causes are:
- Ovulation problems
- Tubal blockage
- Male-associated infertility
- Hormonal imbalance
- Uterine problems
- Previous sterilization operation on the male/female
- Tuberculosis (TB) of the genital tract
- Anatomical defects in either partner
- Medical conditions like thyroid disease, diabetes.
Therefore, it is seen that for a woman to conceive, intercourse must take place around the time when an egg is released from her ovary. There should be adequate amounts of healthy sperms, her tubes must be patent, her uterus prepared to receive the fertilized egg and her Other factors contributing to infertility are:
- Advanced maternal age – fertility declines sharply after 35 years of age due to decreased quality of eggs
- Weight – over or underweight
- Genital infections
- Environmental toxin-like pesticides
- Genetic causes
In about 15 per cent of cases the infertility investigation will show no abnormalities. In these cases abnormalities are likely to be present but are not detected by current available methods.
Once a couple visits a hospital for infertility a detailed general, medical sexual history is taken. Obstetric history is of importance in case of women with secondary infertility. Lifestyle pattern is taken into account since the intake of alcohol, smoking, lack of exercise can affect fertility. Men working in high temperatures expose their testicles to heat that can affect fertility. A thorough general physical examination is followed by a battery of tests. Basic investigations include sperm count, ultrasound, ovulation studies and testing for tubal patency. Treatment depends upon the diagnosis.
If tests do not reveal abnormalities the couple is asked to make lifestyle changes. Abstinence from alcohol, smoking, drug abuse and maintenance of optimal weight for height is required. Those with diabetes or thyroid diseases need to have these issues addressed before contemplating pregnancy. Hyperprolactinaemia is a condition in which there are secretions from breasts without the presence of a pregnancy/ delivery. This is due to raised levels of a pituitary hormone called prolactin which interferes with conception and can be normalized with drugs. Tuberculosis of the genital tract if present, need to be treated with long-term anti-tubercular drugs before conception is attempted.
Low sperm counts and motility in males can be improved with drugs. Males with varicocele, hernia, hydrocele, phimosis, undescend testes, blocked vas (the tube that carries the sperms from the testes to the penis) need to have surgical treatment to improve their fertility. Sometimes antibodies are produced against sperms which may hamper conception. This issue needs to be addressed.
Couples with sexual dysfunction need counselling. Those with a healthy sex life are taught to time intercourse according to ovulation. Those with ovulation failure are given ovarian stimulation medication. Patients with polycystic disease may not respond to the usual oral drugs for ovulation induction and need injectable hormones that could have side effects. If tubes are blocked they can be opened up surgically or bypassed altogether by resorting to in vitro fertilization (IVF).
Other methods to enhance conception rates include IUI – intrauterine insemination wherein the good quality sperms are segregated in the laboratory, collected in a syringe and inserted directly inside the uterus with the help of a fine plastic tube. This is usually done for low sperm count, unexplained infertility or a hostile cervix with thick mucous that decreases sperm penetrability.
The ultimate diagnostic tool in the armory of an infertility specialist is laparoscopy/ hysteros copy. This is a minimally invasive procedure done under general anaesthesia that can, in the same sitting, diagnose and treat conditions that interfere with fertility. The inside of the uterus is viewed with the help of a hysteroscope. Adhesion if present can be broken; polyps and fibroids removed; tissue samples can be taken for histopathology and for the diagnosis of genital tuberculosis. Falloposcopy views the inside of the fallopian tubes from the uterine end and can open up proximal obstruction.
Laparoscopy views the inside of the abdominal cavity and is a useful tool in infertility. Adhesions can be broken, ovarian cysts removed and blocked tubes recanalised. Endometriosis is a condition wherein the endometrium (the internal lining of the uterus) is disseminated inside the abdomen where it bleeds during menstruation leading to adhesions, chocolate cysts of the ovaries and sub-fertility. These too can be treated by laporoscopic cauterization of the endometriotic tissue and removal of the chocolate cysts.
If the above treatment modalities fail there are artificial reproductive techniques (ART) like in vitro fertilization (IVF) and embryo transfer (ET) that can help a majority of infertile couples. For the remaining unfortunate few there is always the option of an adoption.
Though infertile couples are under immense emotional stress and social pressure they need not lose heart. There is a vast array of treatment options that can help them have their heart’s desire. All they need is perseverance and a positive approach to life.