Male Infertility | Female Infertility
We provide quality infertility treatments at an affordable cost. We specialize in IVF, ICSI, Egg Donation, Embryo Donation, natural infertility treatments and male/female infertility services.
1. What is infertility?
Male/Female Infertility is defined as the incapability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular unprotected intercourse.
2. What is the incidence of infertility worldwide?
According to the World Health Organization (WHO), 10-15% of couples experience infertility in one form or the other. Globally, this means about 75-100 million people suffer from this problem
3. Is infertility exclusively a female problem?
The incidence of infertility in males and females is almost equal. 30-40% of infertility is entirely due to a female problem and 35-45% exclusively due to male problems. Some problems in both partners are found in about 10-15% of the couples, whereas in only minority of 5-10% cases, the cause remains unexplained which is called unexplained infertility
4. What are the causes of infertility?
A. The most common causes of female infertility include ovulatory problems and anatomical abnormalities such as damaged fallopian tubes. Some lesser known causes in females are endometriosis, hyperprolactinemia, thyroid gland related problems etc. In developing countries like India, infections in the womb like gonorrhoea, chlamydia and tuberculosis hugely impact fertility.
B. Reasons of male infertility can be divided into three main categories:
- Sperm production disorders affecting the quality and/or the quantity of sperm
- Anatomical obstructions
- Other factors such as immunological disorders, endocrinal problems or failure of testis to respond to the hormonal stimulation triggering sperm production.
a) PCOS: Polycystic Ovarian Syndrome (PCOS), is an ovulation disorder which affects 7-8% of all women. The researchers claim it to be genetic condition though several factors may contribute to it. The main symptoms include irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity, high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound. To increase fertility the treatment possibilities are mostly focused on regulation of the periods in women. For this, several drugs are used (Clomiphene Citrate, Bromocriptine, Gonadotrophins) and weight loss is recommended. In many cases the cycle will be ovulatory and regulated by these treatments. Newer oral antidiabetic drugs such as Metformin are being more frequently used to treat PCOS, with very good results. Apart from this, one can electro coagulate the ovarian surface using a laparoscopic surgery, especially in those cases where women have highly elevated levels of LH hormone. In cases of failure to achieve a pregnancy to Gonadotropin injections are used to induce ovulation. This may be combined with IUI (Intrauterine insemination) procedure also. Resistant cases may be recruited for ART procedures such as IVF of ICSI.
b) Damaged fallopian tubes:
The invitrofertilisation treatment (or IVF) was initially developed for patients facing infertility due to damaged fallopian tubes. Later on the treatment indications were broadened to include cases of unexplained infertility and male infertility. Even until now, tubal damage still accounts for a large number of all IVF treatments. In developing countries like India, genital tuberculosis is a big problem which may lead to blocked tubes. In addition, tubal damage may be the result of sexually transmitted diseases (like Chlamydia or Gonorrhea). Pelvic Inflammatory Disease (PID), gynaecological surgeries, caesarean sections, tubectomy or complication of appendicitis. The patients with damaged/blocked tubes suffer from infertility and are at a high risk of having an ectopic pregnancy.
Endometriosis itself may not be a disease in itself but may be the manifestation of a basic chemical or physiological abnormality that affects the tubal mobility or immune system resulting in endometriosis in patients with retrograde menstrual flow. Thereby endometriosis may not be the cause, but the result of it. Endometriosis is generally diagnosed at the time of laparoscopy and we can treat it simultaneously using Lasers, electric current and scissors. In fact, with the invention of operative laparoscopic surgery, very few people need to undergo the traditional method of opening the abdomen. Endometriosis can also be controlled by using various drugs such as Danazol, GnRh analogues or progesterones which help many patients to conceive. The remaining patients may have to take the help of IVF or ICSI treatment. In our unit, we have found that ICSI gives better results than IVF.
d) Age related infertility
Fertility decreases with increase in age. A woman in her 20s and 30s has a 20-25% chance of conceiving naturally but for a woman in her early 40s, the chance is only 5-10% chance. In IVF clinics, usually women over the age of 35 are seen twice as commonly as younger women. In fact, age is the single most important factor determining the outcome by IVF treatment. The main reason for decrease in fertility with age is due to declining quality of the woman's eggs. Although it is not possible to improve the quality of the eggs, women in their 40s or 50s can only conceive using the techniques which can improve IVF outcome. For example, by increasing the drugs used to induce ovulation which will increase the number of eggs that develop in a given period, thereby increasing the chances of fertilization leading to pregnancy. Egg donation is most commonly used method to increase the chance of pregnancy in women with age-related infertility problems using either a relative or anonymous donor. To predict a woman's fertility blood tests that are commonly recommended are FSH (Follicle Stimulating Hormone) and E-2 (Oestradiol) which are carried out on the third day of the menstrual cycle. The higher the FSH, the lesser are the chances of woman to achieve a pregnancy. With increasing age the FSH levels increase but sometimes high FSH levels are also seen in women who have poor quality eggs.
e) Ectopic Pregnancy
When a pregnancy does not occur in the uterus it is called an Ectopic pregnancy or Extra Uterine Pregnancy (EUG). The most common site of ectopic pregnancy is the tube but sometimes it may occur at other sites like cervix, ovary or the abdomen. The incidence of EUG is about 1% but the risk increases during IVF treatment.
The most common risk factors for EUG are PID, Genital TB, previous history of a EUG, salpingitis, Chlamydia infection, endometriosis, previous history of surgery or tubes, appendix etc.
The symptoms are similar to those of an abortion including a positive pregnancy test with or without vaginal bleeding and abdominal pain. The condition is diagnosed after a thorough examination and an ultrasound together with serum BHCG levels. The treatment depends on the size and site of ectopic. Most commonly, laparoscopy is used to remove the ectopic pregnancy but sometimes medical management may also be offered to the patient. Alternatively, drugs may be injected directly into the ectopic pregnancy under ultrasound guidance.
f) Recurrent miscarriage
Recurrent miscarriage affects 1-3% of all females. The chances of a pregnancy ending up in an abortion are about 18-20% after one and about 20-25% after two episodes of miscarriage. About 50% of pregnancies that end up in an abortion in the first three months have major chromosomal abnormalities. This incidence decreases to 30% in second trimester losses and about 5% in the last trimester. Other possibilities might be hormonal disturbances, abnormality of the immunological system, anatomical abnormality of the uterus, infections lifestyle problems like drug addiction, alcohol use, cigarette smoking, excessive caffeine intake etc. In about 50% of patients, no cause would be found. The treatment of the problem would depend on the cause. For example:
- If the patient has uterine fibroids or polyps she is advised laparoscopic surgery.
- If she has a uterine septum, it could be corrected hysterocopically
- In case of hormonal dysfunctions called luteal phase defect or LPD progesterone is prescribed.
- In case of infections, antibiotics are given.
- If there are immunologic factors, aspirin therapy is prescribed sometimes along with heparin therapy.
Recent advances in the field include injecting lymphocyte cells derived from the husband into woman's body.
For a male to be fertile, the testis should produce millions of sperms which are then transported to the epididymis where they mature. Then they travel through the vas deferens to the seminal vesicles where the seminal fluid gets mixed with the sperms. Then through the ejaculatory duct and the prostrate, the semen is expelled through the urethra and then ejaculated through the penis.
a) WHAT will GO WRONG?
A defect during the fertilization stages in your reproductive system might be the reason for your infertility. In majority of the cases you would be diagnosed as infertile as a result of a defect in production of the sperms, obstruction in the transport of the sperms or the sperm quality. Each problem has a cause which needs to be understood. An understanding of the problems may be a step towards treating infertility.
The cause of the problem may be due to multiple sex partners, sexually transmitted diseases, past history of orchititis or epididymitis excessive drinking, smoking, use of marijuana, cocaine, opiate, heroin etc.
b) Cystic fibrosis and male infertility
Males with cystic fibrosis have congenital absence of vas deferens which connects testis and epididymitis to the ejaculatory duct. Therefore the sperms cannot reach the penis. Testicular sperm aspiration (TESA) is done to obtain sperms for ICSI which gives excellent results Cystic fibrosis is more prevalent in European population and its incidence is less in Asians. Cystic fibrosis is a recessive genetic disorder and any carrier should get the female partner screened for the abnormal gene.
Q. 4 When do you need to see a specialist?
It is important to find a Specialist who is trustworthy and comfortable to talk to and has enough experience in evaluating fertility of a patient. You need to consult the specialist if :
- You are concerned that something is wrong.
- You are 35 years of age or older and have been trying for six months
- You have irregular periods or don't have periods at all.
- You have been attempting pregnancy for more than two years
- You have been undergoing medical treatment for one year and have not conceived
- You have a history of abdominal or pelvic surgery.
- You have a history of pelvic infections, hormonal problems, endometriosis, fibroids, DES exposure, excessive facial or body hair, or a sperm problem that has been identified
- You are considering having a laparoscopy or hysteroscopy
- You have been on clomiphene for more than three months with no success and there is no proposed change for your treatment in the months to come
- You report pelvic pain, heavy periods, and/or bladder or bowel symptoms around the time of menstruation and the doctor does not suggest you to have a hysterosalpingogram or laparoscopy to determine the cause of the symptoms
- A fibroid or tubal damage has been noted on a hysterosalpingogram
Q. 5. What does a Fertility Evaluation Demand?
The first step in evaluating fertility is to have an in depth medical and personal history. This includes information from the couple including past medical and surgical history, current findings, occupational risks, history of sexual development, previous use of contraception, past gynecological and obstetrical history, and current sexual practices.
Following evaluation, the following queries are solved:
a) Is the sperm quality adequate?
Semen analysis is the single most important test to evaluate male fertility. It gives information about the volume of semen, number of sperms, its motility, shape and structure. For test, the sample is collected by masturbation into a sterile container.
b) Is the female ovulating every month?
Regular menstrual cycles, a biphasic BBT chart, and detection of Luteinizing Hormone (LH) in urine are indicators of ovulation, In case of doubt, a transvaginal ultrasound or a blood test may be performed.
c) Are there any barriers that prevent the egg and the sperm from meeting?
The common causes include tubal blockage, presence of endometriosis, adhesions, hostile cervical mueus etc. The most common test that are done are hastero-salpangography which assesses whether the fallopian tubes are open or not and laparoscopy which permits visualization of pelvic organs through very small incision. With additional small incisions, several conditions that may be the cause of infertility could be treated simultaneously
Is the endometrial lining receptive?
For the embryo to implant into the uterus, the endometrium should be receptive. Factors that may interfere with implantation include:
- Inadequate levels of progesterone
- Absence of proteins (beta 3 integrins) which helps the embryo to stick to the uterine lining
- Irregularities of uterine lining like fibroids, polyps etc.
What is to be done next?
When there are difficulties in conceiving, there are various ways to solve them
- If ovulation is a problem – oral and injectable medications are available.
- When tubes are blocked they can be repaired using laparoscopy and hysteroscopy. If the repair is not possible, IVF is advised
- Intrauterine insemination allows the sperm and egg to come close to each other if the conditions are not conducive naturally
- When sperm quality or quantity is an issue various techniques ranging from IUI (Intrauterine Insemination) to IVF (Invitro Fertilisation) to ICSI (Intracytoplasmic Sperm Injections) are available or doner sperms from semen bank could be used.
- In case of fibroids, polyps, adhesions, endometriosis etc., reproductive gynaecological surgeries are available for correction of the problems.
- If all the procedures have failed, IVF is a good alternative.
- For elderly women who do not produce good quality eggs or have exhausted their ovarian reserves and are postmenopausal, egg donation or embryo donation provides a good alternative.
With appropriate treatment about 50-60% infertile couples conceive. An additional 40-50% would conceive by adopting an IVF/ICSI procedure.
Though infertility itself is not a disease it has a physiological condition itself doesn't cause physical unhealthiness, it will have a significant emotional impact on the couple and people it affects. Feelings like anger, sadness, guild and anxiety are usually experienced by the patients and may affect their self confidence and self esteem. Although highly advanced treatments are nowadays available for the couple yet they should decide in their own capacity, how far they are willing to go to achieve a pregnancy.
Tests that are recommended to evaluate your fertility
Advice concerning fertility evaluation depends on your current physical, mental and fertility condition. In common, the tests that are recommended for the female partner are as follows:
- Serum hormone tests
- Follicle stimulating hormone (FSH)
- Leutinising Hormone (LH)
- Estradiol (E2)
- Thyroid stimulating hormone (TSH)
- Fasting glucose
- Screening / Virology Testing
- Hepatitis B
- Hepatitis C antibody
- VDRL for Syphilis (RPR)
- HIV Antibody 1 and 2
- Torch Panel
- Cervical smear
- Type and Rh factor
- Clomiphene Citrate Challenge Test (CCCT) is an indicative test used to provide information about the ovarian reserve.
- Hysterosalpinogram (HSG) is a radiological procedure which uses a particular dye or fluid that is injected into the uterus and fallopian tubes to check for tubal patency and uterine contour.
- Hysteroscopy is a diagnostic procedure performed utilizing a hysteroscope to check if there are any fibroids and/or polyps present in the uterine cavity, and to remove them if they are found. This procedure is normally scheduled between days 6-11 of menstrual cycle.
- Diagnostic/ Operative Laparoscopy: All factors can be accessed in one shot. It is a gold standard test for female fertility. Any factors like PCOD, adhesions, subserous fibroids can be corrected simultaneously.
- Semen Analysis and Culture
- Virology/ Screening Tests
- Hepatitis B
- Hepatitis C antibody
- VDRL for Syphilis (RPR)
- HIV Antibody 1 and 2
- Torch Panel