At a glance:

What is infertility?

Infertility is the inability to conceive after a year of consistent and unprotected intercourse. Conception and pregnancy involve several complex processes in both the partners. Any problem in these processes can lead to infertility.

Ideally,  

• The female body releases an egg from one of her ovaries which has to pass through the Fallopian tube to reach the uterus (womb).
• The male body produces sperm which has to reach the egg at the site of fertilization (uterus).
• The fertilized egg should then implant itself inside the uterine wall for pregnancy to ensue.

Infertility is a common problem seen globally. Both male fertility and female fertility are a concern. Female factor accounts for one-third and male factor accounts for one-third of infertility cases. The remaining one-third of the infertility concerns are related to both male and female factors together.

By when should a couple see an infertility specialist?

Ideally, couples must seek help after consistently trying for a year. However, couples with below conditions should not delay infertility care when they are trying to get pregnant:

• Irregular or no periods or very painful periods
• Endometriosis
• Pelvic inflammatory diseases
• More than one miscarriage
• Surgery on pelvic organs
• Suspected male infertility factors
• History of cancer treatments

It is important to visit a healthcare provider before planning to conceive. Prenatal tests, genetic screenings and counseling ensure that problems are identified early and suitable actions are taken. These sessions not only help in identifying fertility issues but certain chromosomal defects and birth defects also.

What causes infertility in women?

Pregnancy is achieved in women when their ovaries, Fallopian tubes and uterus are intact. Conditions affecting these organs can cause fertility problems. While in some women, a combination of factors results in infertility, in others, there is no identifiable cause. Briefly, the causes of female infertility include;

• Ovarian factors: Menstrual conditions such as anovulation, PCOS (Polycystic Ovarian Syndrome), diminished ovarian reserve, premature ovarian insufficiency (early menopause) and menopause.  
• Tubal (Fallopian tube) factors: Fallopian tube obstruction such as tubal occlusion or damage to Fallopian tube. Inflammation of Fallopian tube due to pelvic inflammatory disease, endometriosis or adhesions.  
• Uterine & cervical factors: Abnormal shape of the uterus, uterine fibroid, uterine polyps, uterine septum, intrauterine scar tissue, blocked cervix and other anatomical abnormalities.
• Pelvic adhesions (scar tissues that bind the pelvic organs together) may arise from pelvic infection, pelvic surgery, appendicitis or abdominal surgery.
• Hormonal factors: Abnormal functioning of hypothalamus and pituitary gland due to aging or health conditions such as tumors.

What are the risk factors for infertility in women?

• Age: Female fertility declines sharply after 35 years. However, in a few cases, the decline begins at a younger age due to reduced egg reserve.
• Gynecological problems such as previous ectopic pregnancy or more than one miscarriage.
• Cancer and its treatment, both radiation and chemotherapy, can potentially impair female fertility.
• Medical conditions such as diabetes, epilepsy, and thyroid and inflammatory bowel diseases.
• Lifestyle factors such as stress, being overweight or underweight, excessive workout, alcohol consumption and smoking.

What causes infertility in men?

Infertility is often thought of as a concern related to females alone, but one third of infertility cases are related to males. Briefly, causes of male infertility include;

• Testicular factors: Undescended testicles and Varicoceles (enlarged veins in the testicles) and childhood infections like mumps.
• Abnormal sperm production: Certain pre-existing health conditions or genetic defects may affect sperm count, quality, or motility.
• Problems with thesperm transport apparatus: Obstruction at Vas Deferens or its associated duct.
• Problemswith delivery of sperm: Premature ejaculation, problems during intercourse (erectile dysfunction), etc.
• History of infections: Inflamed testicles (Orchitis) and bacterial infection that causes scarring and blocked tubes within the epididymis and Vas Deferens.
• Medical conditions such as diabetes.
• Hormonal factors: Abnormal functioning of hypothalamus and pituitary gland due to aging or health conditions such as tumors, or other reasons.
• Genetic factors: Klinefelter’s syndrome, Y-chromosome microdeletion, the problemwith Y-chromosome, and other less common genetic disorders may affect sperm production.

What are the risk factors for infertility in men?

• Age: Men of age 40 years and above have an increased risk for infertility and medical conditions in off-springs. Male fertility is thought to decline with age, although to what extent is unclear.
• Corrective surgeries for conditions such as a hernia, undescended testes or twisted testicles.
• Cancer and its treatments, both radiation and chemotherapy, can potentially impair male fertility.
• Medical conditions such as diabetes or hormonal problems.
• Lifestyle factors such as stress, being overweight or underweight, excessive workout, excessive anabolic steroids, alcohol consumption and smoking.Occupational exposure to chemicals or radiation and excessive exposure to high temperatures (hot bath, steam bath).

Can my OB/GYN treat infertility?

In many cases, difficulty in conceiving may be resolved by a gynecologist. A gynecologist may perform basic infertility evaluation, he/she may refer to an infertility specialist when a problem is noted or suspected.

How do doctors identify infertility problems in couples?

Diagnosing infertility involves –

• Medical and sexual history of partners
• Physical examination
• Female fertility tests – Ovulation and ovarian reserve testing, HysteroSalpingoGram (HSG), transvaginal ultrasound, hormone testing and ovarian function tests (FSH, pituitary hormone). Rarely, hysteroscopy, laparoscopy or genetic testing may be performed.
• Male fertility tests – Semen analysis and testicular biopsy, trans-rectal/scrotal ultrasound, genetic testing and hormone testing.

A team of expert infertility specialists, andrologists and embryologists together evaluate the possible causes of infertility and plan an individualized course of treatment.

What are the different treatments available for infertility?

Treatment is decided based on the cause and duration of infertility, couple’s age, and personal preferences guided by risks, benefits and success rates of all the available treatment options.

Different treatments include:

• Medical management; fertility boosting medication.
• Surgery or Minimally invasive corrections;
  • – For males: Varicocele surgery, laparoscopic varicocelectomy, vasal reversal, vasovasostomy, vasoepididymostomy and Trans-Urethral Resection of Ejaculatory Duct (TURED) in ED Obstruction.
  • – For females: Laparoscopic and hysteroscopic surgery for blocked Fallopian tubes, adhesions, laparoscopic ovarian drilling, myomectomy for fibroid removal, etc.
• Ovulation induction is the process of medically inducing ovulation, so one or more eggs are released from one or both of the ovaries.
• Intrauterine insemination also called as artificial insemination, is a process where the prepared sperm from the partner or donor is placed in the woman’s uterus. Sometimes, ovulation may be induced through medicines to increase the chances of conception. The method is used to treat mild male factor infertility and unexplained infertility.
• Assisted reproductive technologies such as In Vitro Fertilization (IVF) and Intra-cytoplasmic Injection (ICSI). Both of these methods are egg fertilization techniques performed in the laboratory. While IVF is the fertilization of an egg with sperm using natural selection, ICSI is manual selection and injection of sperm into the egg to be fertilized.
• Andrological procedures such as Micro-TESE. Microsurgical Testicular Sperm Extraction (MicroTESE) is a minimally invasive surgery wherein the sperm is extracted from the inside of the testicle. The method finds importance in both diagnosis and treatment of male factor infertility.

What is assisted reproductive technology?

Assisted Reproductive Technology (ART) is a group of fertility procedures that help you to get pregnant without the need for sexual intercourse. The process involves handling of egg and embryos in the lab. ART procedures usually involve using egg, sperm or embryo (extracted in-situ or frozen) from the couple, however, sometimes egg, sperm or embryo from donor may be used.

Common ART procedures are:

• In Vitro Fertilization (IVF) is a process of fertilizing the egg in the lab with the sperm, to form and transfer embryos into the mother’s uterus.
• Intra-Cytoplasmic Injection (ICSI) is the process of injecting a selected sperm into the egg to achieve fertilization. As against natural selection, in ICSI, the embryologist chooses the best sperm, removes the tail and then injects it into the egg. This is an invasive procedure and is performed only when absolutely necessary.

Vitrification or freezing of egg, sperm and/or embryo (also known as fertility preservation), is a preventive approach to have the fertility preserved before going ahead with certain treatments (such as cancer treatments) or exposure to radiation or toxic elements. It is also done as a part of IVF procedure.

What are the different ways to prevent infertility?

The good news is that certain forms of infertility issues are preventable. A few ways to increase the chances of getting pregnant are:

• Regular intercourse
• Healthy personal habits: Avoid alcohol, habit forming substances and smoking.
• Exercise moderately: Excessive exertion or sedentary lifestyle both are attributable to infertility.
• Healthy body weight: Keep a check on your body weight. Being underweight or overweight affects reproductive health.
• For women, avoid or limit the intake of caffeine.
• For men, avoid excess exposure to high temperatures such as sauna, hot tubs. Also, look for environmental toxins and occupational exposure to factors that affect sperm/semen quality – such as industrial toxins, chemicals or radiation.

References:

1. Fertility problems: assessment and treatment. Available on: https://www.nice.org.uk/guidance/cg156/ifp/chapter/assisted-reproduction. Accessed on May 14th, 2018.
2. Center for disease control and prevention. What is Assisted Reproductive Technology? Available on: https://www.cdc.gov/art/whatis.html. Accessed on May 14^th, 2018.
3. Mayo Clinic. Infertility. Available on: https://www.mayoclinic.org/diseases-conditions/infertility/symptoms-causes/syc-20354317. Accessed on May 14^th, 2018.
4. Center for disease control and prevention. Infertility. https://www.cdc.gov/reproductivehealth/infertility/index.htm. Accessed on May 14^th, 2018.