All about infertility
Trying for a baby
It is usually accepted that once married you as a couple will conceive naturally and start your family ..but unfortunately this is not as easy as we are all made out to believe. But never give up hope.
'Infertility' is generally used by doctors as a diagnosis when a couple have been having normal, unprotected, sexual intercourse for more than two years without achieving a pregnancy. Because age is such an important element in the fertility of a female, this does not necessarily mean that all woman should wait over two years to be suitably investigated and treated. It is always important to investigate the patients as a couple and to organise suitable and appropriate investigations relating to their particular circumstances. Indeed, it is not just the female that needs to be investigated but the couple should be investigated as both male and female as approximately 50% of all infertility couples have a contributing male factor. Infertility is a very common condition and indeed one in seven of all couples will seek some help during their reproductive lives in trying to achieve a pregnancy. That means that nearly everyone, whether fertile or not, knows someone else who is also going through the same difficult and traumatic time as they are.
Causes of Infertility
There are many causes of infertility both on the male and female and side and we will take the female side first. These are generally broken down into problems associated with the ovary (and in particular the ovary in producing the egg), problems in the fallopian tube allowing the egg and sperm to meet and then the fertilised egg to travel back down into the womb for implantation. There can also be problems within the womb itself which either prevent or reduce the chance of successful implantation. There are other areas outside the womb that can also contribute to the overall infertility status, such as endometriosis.
There are two ovaries, one on each side and they generally take it in turns to produce an egg, one from alternate sides each month. There are many reasons why the ovary may not produce the egg in the best way and the most common of these is in a condition called polycystic ovarian syndrome. This is a very common.hormonal and metabolic condition affecting the ovary. Up to 30% of all women of child bearing age have polycystic like ovaries, but this does not mean they have the full polycystic ovarian syndrome. Patients with PCOS tend to have very irregular periods and tend not to ovulate. There is also a tendency for increased body hair (hirsuitism) and being overweight.
The most common problem affecting the fallopian tube is that of previous infection. Quite often the patient may not even have symptoms of an infection, particularly if the cause is due to Chlamydia. This is a very insidious bug which can cause damage to the fallopian tubes without the patient even being aware! In any infection, the tubes can either be damaged or blocked completely and hence prevent the egg and sperm meeting efficiently. Having damaged fallopian tubes not only can prevent the patient falling pregnant, but, indeed if they do fall pregnant significantly increase their chance of having an ectopic pregnancy (this is where a pregnancy occurs outside the normal place inside the womb).
The womb is a very important area where the fertilised egg implants inside the uterine cavity. It is important there are no problems inside the womb that may prevent the fertilised egg from implanting and growing. Problems can include certain abnormalities the patient can be born with (congenital abnormalities) or things such as polyps and fibroids which grow as the woman gets older. This is not to say that all polyps and all fibroids cause a problem, but they certainly can reduce the chance of the patient falling pregnant as well as increase the chance of them miscarrying. If the patient has had a previous pregnancy, such a miscarriage, then they can also have scar tissue form inside the womb which can again cause a problem in some cases.
Infection can not only damage the tubes themselves but also cover the ovaries and tubes in a 'cling film' like scar tissue called adhesions. These can prevent the tubes working efficiently and prevent the affective release of the egg from the ovary. Other diseased conditions in the pelvis such as endometriosis can significantly decrease the patient's chance of
Some patients, probably around 1 in 6 will, still not have an obvious cause for their infertility, even after being thoroughly investigated. This is sometimes termed 'unexplained infertility'. This does not mean that there is not a problem there, it just means that with present techniques and technology that it is not easy to find. The sorts of things that can contribute to unexplained infertility include genetic problems within the egg itself, microscopic damage within the fallopian tube, (so that even though it appears open it is not functioning properly) through to problems with the egg/sperm interaction and fertilisation and implantation itself. There are several different treatment options that can be
discussed with patients with unexplained infertility and these should be fully discussed with the appropriate clinician after they have made a decision about the couple suffering from unexplained infertility.
It is absolutely essential that patients are investigated in an appropriate fashion, by experienced infertility specialists. As previously mentioned, investigations should take place both on the male and female side and although there are multiple investigations that can be performed, some of the basic ones include hormone tests, ultrasound and often an x-ray called a hysterosalpingogram (HSG) which checks the inside of the womb and the inside of the tubes. Depending on the results of these on the female side then quite often a test called a laparoscopy may be performed which requires the insertion of a very small TV camera through the belly button, under an anaesthetic. This allows us not only to inspect what is happening in the pelvis, but also to treat things such as adhesions and any ovarian cysts. It is also the most appropriate way to treat other disease such as ectopic pregnancies. This is often called 'keyhole' surgery. It is also essential that a comprehensive semen analysis is performed on the male.
At least one, and preferably two, semen analyses should be performed approximately four weeks apart to get a good idea as to what the status on the male side is. Sperm counts and the way the sperm move (motility) can go up and down like a roller coaster so it is important that if a low count is obtained that a repeat sample is produced. If the second sperm count is also low then it is important the male is investigated further with tests such as hormone profiles, and if appropriate, further blood testing.
It is very important that when a couple start trying to achieve a pregnancy then they try and make themselves as healthy and as fit as possible. If either partner smokes it is very important that this is either greatly reduced or preferably stopped completely. Smoking of both the male and female side can significantly affect their fertility and may make a difference between them falling pregnant or not with whatever treatment option is decided upon. If either partner is significantly overweight then this can also reduce their fertility. This is particularly the case on the female side and indeed being overweight not only reduces your chance of falling pregnant (even with IVF) but also increases substantially the chance of a miscarriage occurring. It is therefore important that if a partner is overweight that they try and reduce this in a healthy way, with the help of a dietician if necessary. Exercise is also a key factor in reducing weight as well as reducing the stress levels often associated with such a difficult time. Alcohol intake is a controversial subject in so far as some practitioners say that all alcohol should be stopped, but most people believe that there is very little hard scientific evidence to substantiate this.
Most infertility specialists believe that the occasional glass of alcohol probably does no harm at all and indeed may even help in relieving stress in difficult times! The most important thing here is that it is in moderation and not in excess. It is important that both are having a healthy diet and if necessary the addition of a multi-vitamin tablet often does no harm. The most important tablet though on the female side is that of Folic Acid as this has been scientifically shown to significantly reduce the chance of neural tube defects, such as Spina Bifida. 400 micrograms should be taken on a daily basis, starting approximately three months before you start to try and achieve a pregnancy and if a pregnancy is achieved then all the way through until approximately 12 weeks of the pregnancy.
There are many sorts of affective treatment options in infertility but they depend on what the underlying diagnosis is. If for instance there is a problem with ovulation then either tablets or injections can be given to stimulate the ovary into producing an egg in an efficient way. If the tubes are damaged or blocked then IVF is not the only option but indeed tubal microsurgery, in skilled hands, can often give much better success rates than that of IVF alone. If there are problems inside the womb such as fibroids or scarring then these can be very carefully removed and again excellent pregnancy results obtained. If the sperm count is low on the male side then unfortunately in most circumstances there is very little that can be done. The man, has previously mentioned, needs to be appropriately investigated but often no direct cause can be found and it is just a case of trying to use the sperm in a more efficient way to help achieve a pregnancy. This may include techniques such as IVF (test tube babies) or even IVF with ICSI (Intra cytoplasmic sperm injection). The second technique is where individual sperm are directly injected with a very fine glass needle into the female egg. This allows us to use extremely small amounts of sperm that would otherwise not be able to fertilise the eggs.
It is now 21 years since the birth of the first IVF baby, Louise Brown. Since then the techniques of IVF have changed quite a lot but surprisingly the success rate of IVF, even in 2001, on average, is still only 19% per cycle started. That means that just less than 1 in 5 cycles actually ends up with a baby at the end of it. Although IVF is an extremely good treatment for some conditions it must always be remembered that it is only one option in some patients and all other options should always be fully discussed. It is therefore important when being investigated or treated for infertility to seek out a centre that can offer all the appropriate investigations and treatment options rather than just IVF.
A basis IVF cycle involves the stimulation of the ovaries by certain drugs that are injected to get the women's ovaries to produce not one egg as she normally would, but on average around 10 to 12 eggs. These are then collected via a fine needle through the back of the vagina, either under some sedation or general anaesthetic and are then fertilised with her partner's sperm. They are generally grown in the laboratory for two or three days and the best two or three then chosen and replaced back in the women's womb. On average, even with good quality eggs, only approximately 60% of any eggs will fertilise and some of these with develop faster than others and allow selection for the ones to be replaced. It is important during the stimulation phase that the patients are monitored correctly to make sure the ovaries are not either under responding or, more worryingly, over responding. If ovaries do over respond they can result in a condition called ovarian hyperstimulation syndrome which can be life threatening.
The success rates from IVF depend on many factors such as the cause of the infertility but the most important one is the age of the female partner. Unlike a man who continually produces sperm up until he is 60 or 70, a women is born with her quotient of eggs and these tend to age with her. Success rates of a patient around 25 can be as high as 50% but when a lady is over 40 then they drop dramatically to less than 10%. There are a whole range of different protocols which can be used in IVF which is outside the scope of this article. Patients requiring IVF should discuss these with their own individual clinic.
Infertility is a very common and very distressing condition. It is extremely stressful for both couples and there are several important points to remember. They first of all should be investigated in a timely fashion, that is generally accepted as being after two years of trying if the female patient is under 35 and has no other obvious problems. Most clinicians agree that the couple should be investigated after one year of trying if the female is 35 or over. The couple should be investigated thoroughly to allow a diagnosis to be made, if possible, and after this diagnosis has been made then appropriate treatment options should be fully discussed with the couple to decide what is best for them. Although IVF is always thought of as the first option in some patients, there are often other options, particularly surgery that may be appropriate and should also be discussed. During the investigation and treatment of infertility the couple should be
given full support from the clinic and counselling should be offered. There are patient support groups in most large clinics which can help to relieve these high levels of anxiety that are associated with this diagnosis. If appropriately diagnosed and treated, most couples will have a significant chance of achieving their desire with a healthy child.
This article is only a small tip of a very large iceberg and should not be seen as complete and exhaustive. Further details should always be asked directly from the patient's clinician during their investigations and treatment.