Infertility

Infertility is the failure of a couple to conceive a pregnancy after trying to do so for at least one full year. In primary infertility, or where pregnancy has never occurred. In secondary infertility, one or both members of the couple have previously conceived, but are unable to conceive again after a full year of trying. On average, between 10% and 20% of couples are unable to conceive after one year of trying. Women reach the peak of fertility in their early twenties. Couples in their twenties who are in good physical health and engage in regular sexual activity have about a 25% to 30% chance per month of conceiving. Women in their thirties, particularly those over the age of thirty-five, have less than a 10% chance per month of becoming pregnant.

What causes infertility?

Infertility may be due to problems in the female, the male or a combination of both. In some cases, the cause is not known.

Some common female factors that may cause or contribute to infertility include:

Damage to the fallopian tubes following infection or surgery;

Uterine fibroids;

High levels of the hormone prolactin;

Ovulation problems;

Endometriosis;

Pelvic inflammatory disease;

Galactorhoea (milk leaking from the breasts)

Amennorhoea (absence of periods).

Hostile cervical mucus. This is a condition in which the cervical mucus creates a thick barrier that sperm cannot penetrate.

Sexually transmitted diseases such as chlamydia;

The production of sperm antibodies (when a woman develops antibodies to her partner’s sperm).

Causes and symptoms

Unlike most medical problems, infertility is an issue requiring the careful evaluation of two separate individuals, as well as an evaluation of their interactions with each other. In about 3-4% of couples, no cause for their infertility will be discovered. About 40% of the time, the root of the couple's infertility is due to a problem with the male partner; about 40% of the time, the root of the infertility is due to the female partner; and about 20% of the time, there are fertility problems with both the man and the woman.

The main factors involved in infertility, listing from the most to the least common, include:

Male problems: 35%

Ovulation problems: 20%

Tubal problems: 20%

Endometriosis: 10%

Cervical factors: 5%.

Recent research suggests that psychological issues, such as anxiety resulting from a lack of emotional support, can lead to hormonal problems that affect a woman’s fertility.

Male infertility is often caused by a low sperm count or an anatomical abnormality, such as a palpable dilation of veins in the scrotal area known as varicocoele. Other contributing factors can be attributed to how the sperm move (motility), or an abnormal sperm type. A few reasons for low sperm count include prolonged fever or a recent severe illness, excessive alcohol consumption, endocrine disorders, testicular injury and exposure to toxins, radiation or high heat.

What tests are used to diagnose infertility?

Typically, couples are seen together when diagnosing infertility. The doctor will take a note of the couples' full medical histories and this will be followed by an examination. They will also be asked about the use of prescribed or illegal drugs, alcohol and tobacco, and whether there is a family history of infertility or genetic disorders.

Women can expect questions about their menstrual history, including the age of onset and any difficulties with menstruation. They also will be asked whether they have noticed milk leaking from their breasts.

Women may have to undergo a genital examination, as well as a cervical smear. Blood tests are taken to measure prolactin levels and thyroid function and sometimes to test for certain hormone levels, such as progesterone and oestradiol. A post-coital test, which is similar to a cervical smear, may be required to see if the sperm can penetrate the cervical mucus. Sometimes an ultrasound scan of the pelvis is taken to check for fibroids in the uterine cavity. A laparoscopy also may be performed, in which a lighted camera is passed through a hole in the abdomen to look at the pelvic structures. Occasionally, a hysteroscopy is required, in which a thin, lighted tube is passed into the uterus to directly examine it.

Men will be required to provide a semen analysis. They must abstain from sexual intercourse for three days before providing the sample. If the initial sample is abnormal, another will be required. The volume of semen, the sperm count, how the sperm move (motility), as well as the presence of immature sperm are checked. If the second sample is abnormal, your doctor may advise the man to have a genetic blood test is performed to make sure that there are no chromosomal abnormalities or defective genes that could be passed on to potential offspring. Blood tests also may be taken to determine levels of testosterone.

Male factors

Male infertility can be caused by a number of different characteristics of the sperm. To check for these characteristics, a sample of semen is obtained and examined under the microscope (semen analysis). Four basic characteristics are usually evaluated:

Sperm count refers to the number of sperm present in a semen sample. The normal number of sperm present in just one millilitre (ml) of semen is over 20 million. An individual with only 5-20 million sperm per ml of semen is considered subfertile, an individual with less than 5 million sperm per ml of semen is considered infertile.

Sperm are also examined to see how well they swim (sperm motility) and to be sure that most have normal structure.

Not all sperm within a specimen of semen will be perfectly normal. Some may be immature, and some may have abnormalities of the head or tail. A normal semen sample will contain no more than 25% of abnormal forms of sperm.

Volume of the semen sample is important. An abnormal amount of semen could affect the ability of the sperm to successfully fertilise an ovum.

Any number of conditions result in abnormal findings in the semen analysis. Men can be born with testicles that have not descended properly from the abdominal cavity (where testicles develop originally) into the scrotal sac, or may be born with only one instead of the normal two testicles. Testicle size can be smaller than normal. Past infection (including mumps) can affect testicular function, as can a past injury. The presence of abnormally large veins (varicocele) in the testicles can increase testicular temperature, which decreases sperm count. History of having been exposed to various toxins, drug use, excess alcohol use, use of anabolic steroids, certain medications, diabetes, thyroid problems, or other endocrine disturbances can have direct effects on the formation of sperm (spermatogenesis). Problems with the male anatomy can cause sperm to be ejaculated not out of the penis, but into the bladder, and scarring from past infections can interfere with ejaculation.

Treatment of male infertility includes addressing known reversible factors first; for example, discontinuing any medication known to have an effect on spermatogenesis or ejaculation, as well as decreasing alcohol intake, and treating thyroid or other endocrine disease. Varicoceles can be treated surgically. Testosterone in low doses can improve sperm motility.

Other treatments of male infertility include collecting semen samples from multiple ejaculations, after which the semen is put through a process that allows the most motile sperm to be sorted out. These motile sperm are pooled together to create a concentrate that can be deposited into the female partner's uterus at a time that coincides with ovulation. In cases where the male partner's sperm is proven to be absolutely unable to cause pregnancy in the female partner, and with the consent of both partners, donor sperm may be used for this process. Depositing the male partner's sperm or donor sperm by mechanical means into the female partner are both forms of artificial insemination.

Ovulatory problems

The first step in diagnosing ovulatory problems is to make sure that an ovum is being produced each month. A woman's morning body temperature is slightly higher around the time of ovulation. A woman can measure and record her temperatures daily and a chart can be drawn to show whether or not ovulation has occurred. Luteinizing hormone (LH) is released just before ovulation. A simple urine test can be done to check if LH has been released around the time that ovulation is expected.

Treatment of ovulatory problems depends on the cause. If a thyroid or pituitary problem is responsible, simply treating that problem can restore fertility. (The thyroid and pituitary glands release hormones that also are involved in regulating a woman's menstrual cycle.) Medication can also be used to stimulate fertility.

Pelvic adhesions and endometriosis

Pelvic adhesions and endometriosis can cause infertility by preventing the sperm from reaching the egg or interfering with fertilization. Pelvic adhesions are fibrous scars. These scars can be the result of past infections, such as pelvic inflammatory disease, or infections following abortions or prior births. Previous surgeries can also leave behind scarring.

Endometriosis may lead to pelvic adhesions. Endometriosis is the abnormal location of uterine tissue outside of the uterus. When uterine tissue is planted elsewhere in the pelvis, it still bleeds on a monthly basis with the start of the normal menstrual period. This leads to irritation within the pelvis around the site of this abnormal tissue and bleeding, and may cause scarring.

Pelvic adhesions cause infertility by blocking the fallopian tubes. The ovum may be prevented from travelling down the fallopian tube from the ovary or the sperm may be prevented from travelling up the fallopian tube from the uterus.

A hysterosalpingogram (HSG) can show if the fallopian tubes are blocked. This is an x-ray exam that tests whether dye material can travel through the patient's fallopian tubes. A few women become pregnant following this x-ray exam. It is thought that the dye material in some way helps flush out the tubes, decreasing any existing obstruction. Scarring also can be diagnosed by examining the pelvic area through the use of a scope that can be inserted into the abdomen through a tiny incision made near the naval. This scoping technique is called laparoscopy.

Pelvic adhesions can be treated during laparoscopy. The adhesions are cut using special instruments. Endometriosis can be treated with certain medications, but may also require surgery to repair any obstruction caused by adhesions.

Cervical factors

The cervix is the opening from the vagina into the uterus through which the sperm must pass. Mucus produced by the cervix helps to transport the sperm into the uterus. Injury to the cervix or scarring of the cervix after surgery or infection can result in a smaller than normal cervical opening, making it difficult for the sperm to enter. Injury or infection can also decrease the number of glands in the cervix, leading to a smaller amount of cervical mucus. In other situations, the mucus produced is the wrong consistency (perhaps too thick) to allow sperm to travel through. In addition, some women produce antibodies (immune cells) that are specifically directed to identify sperm as foreign invaders and to kill them.

Cervical mucus can be examined under a microscope to diagnose whether cervical factors are contributing to infertility. The interaction of a live sperm sample from the male partner and a sample of cervical mucus from the female partner can also be examined. This procedure is called a post-coital test.

Treatment of cervical factors includes antibiotics in the case of an infection, steroids to decrease production of anti-sperm antibodies, and artificial insemination techniques to completely bypass the cervical mucus.

What treatments are available?

Increasing your chances naturally

If you have been having trouble conceiving do not give up hope, as spontaneous pregnancy may occur on its own. In many cases, couples are simply not having enough sex at the right time to conceive. To increase the chance of getting pregnant, intercourse should take place around the time of ovulation.

For women with a regular 28-day cycle, ovulation occurs around day 13-15. Women with irregular periods will find it more difficult to pinpoint their most fertile time. Some over-the-counter tests can help you determine the best time to conceive, although no products are guaranteed to be 100% accurate. Indications for ovulation include a rise in body temperature and a thinning of the cervical mucus. A female egg lives only twelve hours, however sperm can survive in the female genitals for close to 72 hours. Sperm that are waiting in the female genitals can immediately fertilise the eggs once ovulation begins so you will increase your chances by having regular sex for a few days before ovulation. Lubricants that contain spermicides, such as K-Y Jelly, should be avoided. In situations where a woman develops antibodies to her partner’s sperm, the use of a condom for thirty days may allow time for the antibodies to decrease and intercourse should then take place during ovulation.

Infertility drugs

If timing intercourse around ovulation does not work, a general physician may then prescribe various courses of treatment, such as stimulating ovulation with a drug called Clomiphene. Side effects include hot flushes, vaginal dryness and ovarian cyst formation. The number of eggs that you release cannot be controlled precisely so there is a chance that several eggs could be released at once thereby increasing your risk of multiple pregnancy. Other drug treatments include the use of either Bromocriptine or Cabergoline, which act to reduce the levels of prolactin. Check with your doctor about possible side effects of any drug prescribed.

What about assisted reproduction techniques?

There are several ways of bringing sperm and egg together to achieve fertilisation. The most commonly performed procedures are IVF (In vitro fertilisation) and ICSI (Intra cytoplasmic sperm injection). IVF is only considered in special cases and is not suitable for everyone. In vitro candidates are women who have experienced pelvic disease, endometriosis or unexplained infertility. The process involves an intensive programme of hormonal treatments and harvesting of the eggs. The eggs are then mixed with sperm in a laboratory, (typically 1000,000 sperm to one egg to allow one or more embryos to form) after which the embryo is transferred to the uterus. The success rate varies, although the average is about 20-30%.

ICSI is often done if the sperm count is low or if sperm are unable to fertilise an egg. One sperm is injected directly into the centre (nucleus) of one egg using a very fine needle. In some circumstances if sperm cannot be obtained from semen they can be taken straight out of the testicles under an anaesthetic. This procedure is known as TESA (testicular sperm aspiration). ICSI has an average success rate of 35-40%.

GIFT (Gamete Intra-fallopian transfer) is less commonly used but is sometimes performed if there are cervical barriers to conception. IUI (Intra uterine insemination) where the sperm are flushed into the uterus via the cervix by means of a fine catheter is also occasionally done.

What else can I do?

As anxiety may contribute to infertility, incorporate stress management techniques into your daily routine.

The importance of pre-conceptual care

If you are trying to get pregnant, regardless of the method, you should drink only in moderation, do not smoke and avoid any drugs other than those prescribed by your physician. Exercise only lightly and avoid hot tubs and saunas, as they may lead to a lowered sperm count or changes in ovulation. Be sure to get plenty of fresh fruit and vegetables into your daily diet, as they contain folic acid, which helps prevent neural tube defects in the baby. Maintain an appropriate body weight, as being over- or underweight can affect fertility. Also, make sure you receive a rubella vaccination if you have not already had one. It is important to note that pregnancy should be avoided for three months after a rubella immunisation.

It is very hard to obtain statistics regarding the prognosis of infertility because many different problems may exist within and individual or couple trying to conceive. In general, it is believed that of all couples who undergo a complete evaluation of infertility followed by treatment, about half will ultimately have a successful pregnancy. Of those couples who do not choose to undergo evaluation or treatment, about 5% will go on to conceive after a year or more of infertility.

Is your body getting the right signals?

Humans are closely tuned to their surroundings - especially when it comes to making babies.  Our bodies reach the peak of fertility only when conditions seem right for raising babies. If there's any sign of illness, malnourishment, or an unhealthy environment, our bodies may decide to put parenthood on hold.

That said, you may feel ready to start a family, but is your body getting the right signals?

Many men and women are putting their fertility at risk without realizing it. If you hope to have children in the future, now's the time to start protecting your fertility. If you and your partner are already struggling to conceive and there's no medical explanation for your problem, a few lifestyle changes may help put you on the road to parenthood.

Maintain a healthy weight                     

The sex hormones of both men and women are closely tied to weight, although extra pounds have little effect on sperm count. However, the stakes for women are much higher. According to the Mayo Clinic, a woman whose body fat is just 10 to 14 percent higher than average may have trouble conceiving. Part of the reason is that an increase in abdominal fat is associated with insulin resistance and a rise in insulin production, which wreaks havoc on sex hormones. When obese women do become pregnant, they are more likely to have miscarriages than lean women of the same age.

Get your exercise but don't overdo it     Regular exercise is a great way to stay trim and healthy. But if you push yourself too hard for too long, you might throw your hormones out of balance. 

Eat a balanced diet -  shortfalls in nutrients such as Vitamin C, zinc, and folic acid can slow sperm production in men. 

Don't smoke

Smoking can slightly lower a man's sperm count and may even contribute to impotence. Smoking is especially hard on prospective moms. Smoking can interfere with virtually every aspect of a woman's fertility, from ovulation to early development of the embryo. If you're a female smoker with fertility problems, kicking the addiction should be your top priority.

If you drink, go easy                            

Moderate drinking usually won't lower sperm count in men or harm fertility in women. But large amounts of alcohol (usually defined as more than two drinks per day for men and more than one drink per day for women) may lower your odds for parenthood. 

Stay clear of recreational drugs

Women trying to get pregnant, of course, should avoid recreational drugs and alcohol because of the potential danger to the foetus.

Check what medicines you are taking - some prescription drugs can impair fertility in both men and women. For men, the list of potential culprits includes the heartburn medication Tagamet and several chemotherapy drugs. A woman's fertility may be hampered by certain antibiotics, painkillers, antidepressants, and hormonal treatments. Ask your doctor if any of your medications could be causing infertility. A change of prescription just might solve the problem.

Men, don't take infertility sitting down! Whenever you spend long hours sitting -whether it's in front of a computer screen or behind a steering wheel - the temperature of your scrotum and testes may rise a few degrees. As the heat rises, sperm production can plummet.  If you want to increase your sperm count, the theory goes, it's best not to spend all day planted on your backside. You should also avoid saunas or long soaks in hot baths, which can lower sperm count. A Stony Brook University Hospital study in 2004 found that men may be feeling the heat from a new direction - laptop computers. Researchers found that holding a laptop computer on a man's lap for only an hour raised his testes temperature by 4.9 degrees Fahrenheit, which might be enough to impair fertility. Further research is needed to confirm the findings, say researchers. But at least you don't have to sweat your choice of clothes. Contrary to popular wisdom, tight jeans or briefs won't overheat your testicles or cause infertility.

On the whole, the game plan for protecting fertility looks much like the basic strategy for good health: Watch your weight, exercise, eat well, and avoid smoking and heavy drinking. These habits are good for anyone. With any luck, you can pass them on to your kids.

For as long as people have been having children, they've been trying to understand the mystery of fertility. We've come a long way, but many misconceptions remain.

Here's a look at the top modern infertility myths:

Myth 1: Infertility is almost always a woman's problem.

Fact: When there's an identifiable cause of infertility, about half the time men contribute to the problem. An article in the Journal of Urology in May 2002 explains that a male factor is "solely responsible" in about 20% of infertile couples, and contributes to the problem in another 30% to 40% percent.

Myth 2: Many infertile couples are trying too hard. If they would just relax, they would conceive right away.

Fact: Relaxation alone won't help anyone become a parent. Instead of booking that holiday, infertile couples should schedule a doctor's appointment. One or both partners may have a correctable medical condition that stands in the way of conception. If there's no obvious physical explanation for infertility, a doctor can suggest lifestyle changes that could boost the odds of parenthood.

Myth 3: Most couples can conceive any time they want.

Even under the best circumstances, conception is tricky. It's not unusual for a perfectly healthy, fertile couple to try for several months or more before achieving a pregnancy. And the longer couples wait to have children, the more difficult it can be: By the time the average woman reaches her early forties, half of her eggs are no longer viable. However, most couples who can afford fertility treatments can eventually conceive, if they are open to the use of egg donation.

Myth 4: Women don't start to lose their fertility until their late 30s or early 40s.

Fact: According to a May 2002 report in the journal Human Reproduction, a woman's fertility starts to decline at age 27, although this isn't clinically significant. Most women of this age can still get pregnant, of course, but it might take a few more months of trying. But by the time a woman reaches 35, her chances of getting pregnant during any particular attempt are about half of what they were between the ages of 19 and 26.

Myth 5: Boxer shorts and loose pants are the ideal choice for prospective fathers.

Fact: Researchers at the University of New York at Stony Brook put this piece of conventional wisdom to the test and concluded that underwear style is unlikely to significantly affect a man's fertility. What that comes down to is that wearing roomy shorts probably won't help a man become a father - but on the other hand, it won't hurt, either.

Myth 6: Little can be done to improve a man's sperm count.

Fact: No matter how sparse his troops may be, a man still has reason for hope. Many men who produce little or no sperm have blockages or other treatable conditions. Lifestyle changes - such as quitting smoking, losing weight, and staying away from long, hot baths -may also help.

Myth 7: A man's fertility doesn't change with age.

Fact: While some men can father children into their 80s or 90s, male fertility isn't age-proof. As reported in Human Reproduction, a man's fertility usually begins to dip after about age 35. The decline is generally slow and gradual, but it can speed up dramatically if a man develops a condition that hampers sperm production (such as an infection in the genital tract).

Myth 8: Vasectomy reversals are rarely successful.

Fact: According to a report from the Johns Hopkins Medical Institutes, some patients have a better than 50/50 chance of fathering a child after a vasectomy reversal. However, the longer a man waits to have a reverse vasectomy, the lower the odds.

Myth 9: Infertility means you can't have a child.

Fact: Infertility means that you have been unable to have a child naturally after a year of trying. With the proper treatment, many people go on to have children. In addition, there is a possibility of a couple conceiving without treatment if the woman is ovulating and has one open tube, and the male partner has some sperm in his ejaculate. This rate may be lower than you would hope, but it is not zero. If you're struggling with infertility, you undoubtedly have many questions of your own - and maybe even a few misconceptions. Make an appointment with your doctor and find out where you stand. Thanks to modern medicine, many infertile couples become parents - and that's no myth.