Infertility

What is infertility?

Infertility is the inability to get pregnant after one year of trying. It is a common problem that can affect 1 in 7 couples. 80% of couples having regular sex should conceive within one year.

To get pregnant, there are several processes that must happen. The woman’s body must release an egg from one of her ovaries (ovulation). This egg must go through a fallopian tube toward the womb. The man’s sperm must travel through the vagina, womb and go through the fallopian tube to join with (fertilise) the egg. Then the fertilised egg (embryo) must attach to the inside of the uterus (implantation). Anything that may hinder or interfere with any of these steps may cause infertility. In about 30 percent of couples, no obvious causes of infertility can be found.

• For women, try to conceive when you are still young. Fertility starts to fall at age 34 and diminishes further at age 37, falling quite drastically after 40. Fibroids and endometriosis can occur at any age but tend to be more common in older women.
• Damaged tubes in the female and blocked vas in the males may occur as a result of sexually transmitted infections (STI). Condom use can protect against STI. If you have an infection, seek treatment early.
• Certain infections such as mumps can cause inflammation of the testis and impair sperm production. That is why most children are vaccinated against mumps.
• Problems with ovulation may be due to hormonal disturbance. If you have irregular infrequent periods, see your doctor to see if these hormonal imbalances, for example thyroid dysfunction, can be corrected.
• If you have period pains and painful sex, see your doctor so that, if necessary, treatment can be instituted for endometriosis and fibroids.

Certain lifestyle issues like smoking and being under or overweight can also affect fertility.

What causes infertility?

Female

• Damaged or blocked tubes hence preventing the sperm and egg from meeting.
• Problems with ovulation such as polycystic ovary syndrome (PCOS) where few or no eggs are released.
• Endometriosis, a condition which causes distortion to the female anatomy that can affect the fallopian tube function or may cause a hostile environment that may interfere with fertilisation.
• Fibroids and polyps that can distort the cavity of the womb and impair implantation.
• Premature ovarian failure such that eggs are no longer released. This can occur naturally or as a result of chemotherapy or radiotherapy.
• Age as the number and quality of eggs diminish with age.

Male

• Low sperm count or poor sperm motility which may be a genetic cause. This means fewer sperm manage to get to the fallopian tubes to meet the egg.
• Absent or no sperm. This may result from obstruction in the vas, the tube that delivers the sperm from the testis to the penis, or due to impaired sperm production in the testis.
• Erectile dysfunction, retrograde ejaculation resulting in failure of delivery of sperm in the vagina.

How is infertility diagnosed?

If you have not conceived after one year of regular intercourse without the use of any contraception, it is recommended that you see a doctor. The age of a woman is an important consideration as both the number and quality of eggs decline with age. Hence, it is important to seek medical help early especially if the woman is over 35 years old.

Your doctor will be able to run some tests to identify where the problem may be.

For the female partner, hormonal tests are performed to look for ovarian reserve and to assess for ovulation.

For women who have irregular cycles, hormone tests for thyroid and prolactin levels are also checked.

An ultrasound scan can easily identify any fibroids or cysts. A hysterosalpingogram or ultrasound saline infusion may be offered to assess tubal patency.

Infertility is a common problem. There are many types of treatment tailored to every couple depending on what the cause may be. Seek treatment early as success depends on the age of the female partner.

For men, the semen test is performed after abstinence of three to five days.

How is infertility treated? 

Treatment is directed at the underlying problem.

• Damaged or blocked tubes
  

  Under certain circumstances, surgery or cannulation of the tube may ‘open’ up the tubes. If despite treatment, there is no conception or the tubes cannot be unblocked, then in-vitro fertilisation (IVF) will be the treatment of choice.

• Problems with ovulation
  

  Problems with ovulation such as polycystic ovary syndrome (PCOS). Patients with PCOS who are overweight should lose weight as this may lead to resumption of ovulation. Ovulation induction with clomiphene, letrozole or FSH injection may also be used.

• Endometriosis
  

  Patient with large endometriotic cysts (>5 cm) or with severe pain may consider surgery. If there is still no conception 6-12 months postsurgery, then IVF may be the next step. As endometriosis tends to recur, it is advisable to consider medical treatment to prevent recurrence if fertility is not desired.
  
  If the cyst is not large or there is a recurrent cyst after surgery, then IVF should be considered. This is because repeated operations can reduce the ovarian reserve as ovarian tissue may be removed during surgery.
  

• Fibroids and polyps
  

  Fibroids and polyps that distort the womb cavity can be removed through the hysteroscope, a telescope that allows visualisation of the womb cavity. The camera is introduced through the vagina.

• Premature ovarian failure
  

  Premature ovarian failure such that eggs are no longer released. Under these circumstances, an egg donor or embryo donor is necessary as there is no treatment of this condition. Prior to any cancer therapy, women and men are counselled about how they can preserve their fertility. Men can bank their sperm and women can bank their eggs, ovarian tissue or embryo for future use.

• Age
  

  The number and quality of eggs diminish with age. There is no medication that can reverse the effects of age and that is why for women older than 35, infertility investigations may commence after six months of trying.

• Low or no sperm
  

  Hormonal or chromosomal tests may be performed to find the underlying cause. In a small percentage of men, the cause is hormonal and replacement of hormones may allow the resumption of sperm production.
  
  For men with low sperm count, intracytoplasmic sperm injection where sperms are injected directly into the egg at IVF will give the sperm the opportunity to fertilise the egg.
  
  For men with no sperm, sperm may be obtained directly from the testis or eididymis. As the number of sperm retrieved are low, IVF/ICSI is necessary. For those where no sperm is retrieved, sperm donation can be considered.
  
  For men with erectile dysfunction, psychosocial counselling and medication like Viagra may be helpful.

Other treatments

• Intrauterine insemination (IUI)

  This is a treatment where washed sperm is introduced into the womb with a cannula at the time of ovulation. This is indicated for women with patent tubes, with mild sperm problem or couples with problem of nonconsummation or erectile dysfunction.
  
  IUI may also be performed together with ovulation induction with hormonal injection. This is ideal for couples where the women are younger (<35) with patent tubes and no or mild male factor problem. This may also be for couples with ovulation problems or where no known cause is found.
  

• In-vitro fertilisation (IVF)
  

  IVF is a procedure where eggs are retrieved from a woman and are inseminated with the husband’s semen in the laboratory. The resultant embryo is then placed back into the womb.
  
  To make IVF more efficient, hormonal injections are given to the woman to induce more eggs so that it allows for more opportunities for the eggs to be fertilised. IVF is indicated for the following problems:
  1. Blocked tubes
     
  2. Failure of ovulation with ovulation induction or failure to get pregnant despite ovulation induction
  3. Treated endometriosis or endometriosis with small cysts (<5 cm)
  4. Donor egg or sperm cycles
  5. Surgical retrieved sperm or very low sperm counts
  6. No known cause but no conception after three years of trying (female <35 years old) but may be sooner for those older than 35
  
  Despite advances in IVF, the chances of conception vary from 20-35 percent depending on a woman’s age. 
  

References

1. NHS. (n.d.). NHS choices. https://www.nhs.uk/conditions/infertility/causes/
   
2. Healthdirect Australia. (n.d.). Infertility. healthdirect. https://www.healthdirect.gov.au/about-infertility
   
3. MediLexicon International. (n.d.). Infertility: Causes, diagnosis, risks, and treatments. Medical News Today. https://www.medicalnewstoday.com/articles/165748
   
4. Walker, M. H. (2022, December 19). Female infertility. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK556033/
   
5. World Health Organization. (n.d.). Infertility. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/infertility