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Infertility

Overview

The inability of a woman to conceive or get pregnant and the inability to procreate in the case of a man is known as infertility. When a couple cannot get pregnant after one year of regular unprotected sexual intercourse, they are termed infertile. It can either be due to female factors or male factors. Many new advances have been made in this realm to enable a couple to conceive.

Types

Male infertility: When infertility is due to male factors, it is called male infertility.

Female infertility: When infertility is due to female factors, it is called female infertility.

Epidemiology

Infertility affects about 10-15% of couples. According to CDC, In the United States, infertility affects about 6% of married women aged 15 to 44 years. This percentage increases to about 12% in women aged 15 to 44 years.

Risk Factors

Following are the risk factors for infertility;

  • Age: age of females above 35 or 40
  • Irregular, absent, or painful periods
  • Sexually transmitted diseases
  • Consuming Alcohol 
  • Consuming Tobacco 
  • Stress
  • Lack of exercise
  • Being over-weight or under-weight

Causes

There may be multiple causes of infertility, although 40 % of cases may be idiopathic.

1. Male causes of Infertility

  • Failure to produce healthy semen: Semen is the ejaculate that consists of spermatozoa, secretions from the prostate gland, and seminal vesicles. Inefficient semen may be responsible for infertility. Azoospermia is the absence of spermatozoa in semen. Oligospermia is when the number of sperm in semen is less than normal. Asthenospermia is poor motility of spermatozoa. Teratospermia means defective morphology or a high number of sperm, and lastly, Aspermia means the complete absence of sperm in semen. Semen analysis is an essential investigation to be conducted when an infertile couple visit their doctor for infertility problems.
  • Low-quality sperm: Sperm could be of low quality due to chromosomal abnormalities such as in Klinefelters or a condition such as undescended testes, which is known as cryptorchidism. If this is corrected early in life, normal spermatogenesis may take place. In case of damage to the testes, the sperm may be of low quality, such as in trauma or accidents, surgeries such as vasectomy, and prostatectomy. 
  • Infectious causes include;  Mumps, a viral disease that causes orchitis that leads to testicular atrophy. Other conditions such as tuberculosis, syphilis, and gonorrhea are also particularly harmful to the testes. 
  • Radiation exposure also suppresses spermatogenesis, and cancers of the testes may be responsible for low-quality sperm. 
  • Other factors may include chemotherapy—certain drugs such as calcium channel blockers, Sulfasalazine and  DES. DES has caused infertility in some of the children whose mothers took DES. Steroids, marijuana, and cocaine lower male sperm count. 
  • Endocrinal diseases such as Cushing’s syndrome, diabetes, and thyroid disease. 
  • Smoking, alcohol, and exposure to pesticides also lead to infertility in men. 
  • Being overweight and stressed also play a role in male infertility.
  • Failure to inseminate, such as impotency /premature ejaculation, hypospadias, and phimosis, also leads to infertility.

2. Causes of infertility in females

3. Uterine tubal factors (30%)

  • Congenital absence of uterus or vagina 
  • Large submucosal myomas
  • Endometrial polyp 
  • Tubal occlusion could be due to several reasons such as tuberculosis, post-abortion, after gonococcus, chlamydia infections
  • Cervical factors (5-10%)
  • Cervical mucus hostility 
  • Loss of mucus 
  • Severe prolapse

4. Peritoneal Factors 40%

  • Endometriosis 
  • Adnexal adhesions 
  • Decreased tubal motility 
  • Tubal obstruction 
  • Luteal phase defects 

5. Unexplained (5-10%)

  • Sperm transport and penetration defect 
  • Anti-sperm antibodies.
  • Infertility is also caused by infrequent sexual relations between male and female partners or when there is a lack of knowledge about ovulation or lack of knowledge about proper sexual intercourse, 
  • When sex is painful, the semen may not be deposited in the posterior fornix 
  • Sometimes some kinds of lubricants are used during coitus that is spermicidal, so couples need to be counseled and given proper guidance regarding it. 

Signs

When a woman in a heterosexual relationship with regular sexual intercourse and menstrual cycles cannot become pregnant after 12 months of trying to conceive without using birth control, she and her partner should consult their health care physician. 

Diagnosis

It is vital to obtain a detailed history of the married couple. All the questions regarding the trials, previous losses, previous attempts on treatments, miscarriages, drugs history, medical and surgical history. A thorough physical examination is needed to be performed on both partners, especially to check for any abnormality in the reproductive organs. 

Males' infertility is diagnosed by a semen analysis, ultrasounds, and blood tests. According to World Health Organisation (WHO),  following is normal semen analysis result:

  • Semen Vol. should be over 2ml
  • Sperm count over 2 million/ml
  • Motility over 50%
  • Morphology over 30% normal looking
  • W.b.c s white blood cells < 10 per high power field or 1 x 106  / ml .

It may take up to 2 menstrual cycles to determine etiology in females. Investigations may include;

  • Blood tests; hormone levels for progesterone, estrogen, FSH, LH
  • A pap test 
  • A pelvic ultrasound 
  • An examination of the breasts for unusual milk production 
  • X-ray hysterosalpingogram
  • Laparoscopy
  • Transvaginal ultrasound 
  • Hysteroscopy

Treatment

In up to 25% of cases, the fault lies with the male partner, and in another 25 % of cases, it lies with the female partner; however, no fault is found in 10% of cases. This is known as unexplained fertility.  Such couples need reassurance and guidance about their diet, obesity, anxiety due to overwork or other stressors, and options such as IVF technology.

Treatment should be directed towards treating the root cause of infertility in either of the partners. Treat for general health, anemia, infections, blocked tubes, or other reasons such as fibroids or endometriosis. 

A fertility challenge can be given to women by prescribing Clomiphene Citrate tab 50 mg once /day for three months to induce ovulation. Other medicines used are gonadotropin-releasing hormone (GnRH) analogues, follicle-stimulating hormone (FSH), human chorionic gonadotropin (hCG), and metformin.

Assisted reproductive technology(ART): When the sperm and egg are handled in the laboratory to help the couple get pregnant, it is called ART. The most famous and successful technique is IVF In-vitro fertilization, in which eggs are retrieved from a female and fertilized with sperms in a dish, and then an embryo is transferred in the female’s uterus. Another procedure called Intracytoplasmic sperm injection (ICSI) is also used sometimes, which involves direct injection of healthy sperm into a mature egg. 

Lifestyle Modifications

Infertility can be very stressful. Couples should seek emotional support to combat anxiety and depression as it worsens the situation. Following lifestyle changes should be made to increase the chances of conception;

  • Take a balanced diet with all the nutrients and supplements if needed.
  • Exercise regularly to keep oneself healthy, active, and stress-free.
  • Avoid drinking alcohol and smoking tobacco
  • A healthy weight should be maintained according to BMI (body mass index).
  • Men should avoid bathing in hot tubs or going to the sauna as high temperatures are harmful to sperms.