Sub Fertility

Introduction

Infertility is fundamentally the inability to conceive a baby. Infertility also refers to the state of a woman who is unable to carry a pregnancy to full term. About 40 percent of the issues involved with infertility are due to the man, another 40 percent due to the woman, and 20 percent result from complications with both partners. 

Prevalence of infertility 

• Worldwide between 3 and 7% of all couples or women have an unresolved problem of infertility.  
• Many more couples, however, experience involuntary childlessness for at least one year: estimates range from 12% to 28%. 
• Fertility problems affect 1 in 7 couples in the UK.
• A study conducted by UNFPA in eight districts of Nepal found 7.4% of females have infertility problems.
• Among the women who were reported infertility 40% have tried one or other forms of traditional remedies for infertility (herbs, special foods, dhamijhakri and special puja) (UNFPA, cited from Shrestha D.R, 2012) 

Definition 

According to WHO a couple is described as infertile if the woman has not gotten pregnant after having normal sexual intercourse two or three times a week without using any contraception for at least one year. The term infertile, strictly speaking, should not be used until it is proved that pregnancy is impossible. 

WHO has further defined various types of infertility as follows: 

• Primary infertility: The couple has never conceived despite regular (2-3 times per week) unprotected intercourse for at least 12 months (1 year). 
• Secondary infertility: The couple previously had conceived but is now unable to do so despite 12 months of unprotected intercourse. 
• Sub-fertility: The couple has difficulty in conceiving jointly because both partners may have reduced fertility. 
• Pregnancy wastage: The woman can conceive but is unable to produce a live birth (unable to carry the pregnancy long enough to deliver a living child). 

Is infertility just a woman's problem?

No, infertility is not always a woman's problem. Both women and men can have problems that cause infertility. There is no one definitive factor that causes infertility. 

Causes of Infertility in Women :

• Anovulation: Ovulation is vital to pregnancy, and without the monthly release of an egg there will be nothing for the male sperm to combine with. Failure to ovulate for whatever reason is one of the most common causes of infertility.
• Tubal factors: 
  • Impaired tubal motility, 
  •  Loss of cilia, 
  • Defective ovum pick-up & 
  • Blocked Fallopian tubes due to pelvic inflammatory disease, salpingitis, endometriosis, or surgery for an ectopic pregnancy 
  • Periesophageal adhesion
• Uterine factors 
  • Uterine fibroid 
  • Endometriosis 
  • Uterine neoplasm 
  • Uterine hypoplasia 
  • Congenital malformation 
• Cervical factors 
  • Congenital elongation 
  • Acute retroverted uterus 
  • Second-degree uterine prolapsed 
  • Cervical polyps/tumors 
  • Excessive viscosity of cervical mucous  
  • Cervicitis 
• Vaginal factors- Atresia, transverse septum, vaginitis, chronic infections of the vagina  

Infertility can also occur as a result of some conditions below: 

• Polycystic ovary syndrome (PCOS): This is a condition that often inhibits the ovaries from producing an egg. 
• Early menopause: A women's ovaries stop working before she reaches the age of 40. 
• Pelvic inflammatory disease (PID) 
• Endocrine disorders, Pituitary, Thyroid, and Adrenal problems  
• Chronic long-term illnesses such as diabetes, cancer, or kidney failure may not ovulate. 
• Cushing syndrome: A hormonal disease that can stop the ovaries from releasing an egg.   

Causes of Male infertility 

For men, the most common cause of infertility is abnormal semen, accounting for 75% of all male infertility cases. Some of the conditions are

• Low sperm count & sperm mobility 
• Abnormal sperm 
• Varicocele 
• Ejaculation disorders 
• Bacterial or viral infection of seminal vesicle & prostate gland, prostatitis, TB, gonorrhea, surgical trauma 
• Absence of vas deference 

Defective spermatogenesis: Undescended testes, orchitis 

Coital difficulties: Chordee (painful, downward curving erection) 

Agenesis or destruction of testes, cryptorchidism, torsion of the testes Hypospadias, Urethral stricture 

Prostate and seminal vesicle abnormalities: Chronic prostatitis, seminal vesiculitis 

What increases a man's risk of infertility? 

• Heavy alcohol use 
• Drugs: cytotoxic, antihypertensive, B-blockers, antidepressants, anticonvulsants etc. Environmental toxins, including pesticides and lead 
• Smoking cigarettes 
• Health problems such as mumps, kidney disease, or hormone problems, malnutrition, cancer 

Factors affecting fertility of both sexes 

Age 

•  According to statistics, the biggest drop in fertility levels occurs during our mid-thirties. For women who are aged 35, 95% will fall pregnant within three years of having regular unprotected sex. 
• For women who are 38, this figure falls to 75%.  
• With regards to male age and fertility, it is thought that men over the age of 35 are half as likely to achieve conception in comparison to men younger than 25. 

Stress 

•  Stress does have a direct impact upon fertility by limiting the production of sperm in men, whilst also affecting ovulation within females 

Weight 

Being outside of a healthy weight range can seriously impact fertility. Women who are overweight or severely underweight for example will often find that their ovulation is affected, or in some cases, it may stop entirely. 

Diagnosis and treatment of Infertility 

For male: 

•  Semen analysis 
• Serum FSH, LH, testosterone, prolactin, TSH 
• Routine urine & blood investigation, blood sugar level 
• USG- to visualize seminal vesicle, prostate gland, ejaculatory duct 
• Chlamydia test and genetic testing 

For female: 

• Cervical mucous study 
• Vaginal cytology 
• Hormone estimation- serum progesterone, LH
• Hysterosalpingography 
• Endometrial biopsy
• Chlamydia test and genetic testing 
• USG 

INFERTILITY TREATMENT 

There are three main types of fertility treatment available: 

• Treatment to assist fertility 
• Surgical procedures 
• Assisted conception, which may be intrauterine insemination (IUI) or In-vitro fertilization (IVF) 

Couple Instruction 

•  Assurance 
• To obtain body weight at an optimum of BMI 20-24. 
• Avoid smoking & alcohol consumption. 
• Coital problem: advice to have intercourse during the midcycle & minor psychological problem should be corrected accordingly 

Treatment of male infertility 

• Improvement of general health problem. 
• Avoidance of tight warm undergarments 
• Avoidance of too frequent intercourse may at times improve the sperm count. 
• Supplementation of vitamin E, C, B12, & folic acid. 
• Antibiotics can also be used to clear up infections affecting sperm count. 
• Sperm movement: Sometimes semen has no sperm because of a block in the man's system. In some cases, surgery can correct the problem. 

Treatment of female Infertility 

• General improvement of health 
• Psychotherapy for emotional problem 
• Advice on the timing of intercourse 
• Surgical management e.g. Tuboplasty, myomectomy, enlargement of vaginal introitus & removal of vaginal septum 

Prevention of Infertility 

• Prevent from STIS 
• Maintain healthy practices 
• Avoid unnecessary drugs 
• Protect scrotum from heat 
• Prevent from other infections Avoid chemicals 

 ASSISTED REPRODUCTIVE TECHNOLOGY (ART)  

ART is a general term referring to methods used to achieve pregnancy by artificial or partially artificial means. It is reproductive technology used primarily in infertility treatments. The term includes any reproductive technique involving a third party e.g. a sperm donor. 

Some of the ARTS are mentioned below;

Ovulation induction 

•  Medicines used to treat infertility in women: 
• Clomiphene citrate  
• Gonadotropin-releasing hormone (Gn-RH) analog 
• Human menopausal gonadotropin or hMG 
• Follicle-stimulating hormone 
• Bromocriptine  

Intrauterine insemination (IUI) 

• Insertion of washed semen directly inside the uterus through the cervical canal by using a syringe and cannula. 
• In vitro fertilization (IVF) and Embryo Transfer 
• This is one of the most commonly used procedures. Ovum is combined with a partner's sperm in a dish in a laboratory. Once fertilization has occurred, the resulting embryos develop for 3 to 5 days before being placed in the uterus. One cycle of IVF takes about two weeks. 

Risks of IVF Treatment

Specific steps of an in vitro fertilization (IVF) cycle carry risks, including: 

•  Multiple births 
• Ovarian hyperstimulation syndrome (pain, bloating, nausea, vomiting, and diarrhea) 
• Premature delivery and low birth weight 
• Miscarriage 
• Egg-retrieval procedure (bleeding, infection, or damage to the bowel, bladder or blood vessel) 
• Ectopic pregnancy 
• Birth defects 
• Ovarian cancer 
• Stress (financially, physically, and emotionally)

Success Rates for In Vitro Fertilization 

The live birth rate for one cycle varies by maternal age: 30% to 35% among women younger than 35 years of age and 25% for those aged 35 to 37 years. The success rate ranges from 6 \%-10\% in those older than 40 years of age. Pregnancy in women older than 44 years of age is rare. 

The rate of miscarriages with IVF pregnancies is the same as that with normally conceived pregnancies. An ectopic pregnancy occurs in about 3% to 5% of cases. 

Donor egg or embryo 

If the client's unable to conceive using her own eggs, an egg donated by another woman is mixed with the patient's partner's sperm and the resulting embryo is implanted in the client's uterus. This procedure also can be done with a donated embryo or sperm. 

Gamete Intra Fallopian Transfer (GIFT) 

In this procedure, both the sperm and unfertilized oocyte are transferred into the fallopian tubes using laparoscopy following transvaginal ovum retrieval. Fertilization is then achieved in vivo. 

Zygote Intra Fallopion Transfer(ZIFT) 

Here, a woman's egg cells are extracted from her ovaries and fertilized artificially. Once the zygote has formed, it is transferred into the fallopian tube by laparoscopy or the uterine incision using ultrasound guidance. When the problem is in a male factor, or if GIFT has already been attempted and failed, this method is a viable backup plan. In cases where tubal factor infertility is present, neither GIFT nor ZIFT should be attempted.

Intra Cytoplasmic Sperm Injection (ICSI) 

When the sperm count is low or IVF attempts have failed, this can be helpful in cases of male factor infertility. In this technique, a single sperm is extracted from the ejaculate, the testis, or the epididymis and then inserted into the egg with the aid of a microneedle.

Surrogacy, or use of a gestational carrier 

Another woman carries the embryo of the client, or a donor embryo, to term and gives the baby to the client after birth. 

Prognosis of Artificial Reproductive Method 

Thirty to forty percent of couples became pregnant during the course of the study, or within two years after its initiation. If the pregnancy does take place, however, the risk of miscarriage, ectopic pregnancy, and perinatal mortality all increase by a factor of two.