What is Infertility?

Infertility is the inability to conceive after 1 year of unprotected intercourse of reasonable frequency. Adequate intercourse is defined as at least 4-5x of unprotected intercourse/week. It can be subdivided into primary infertility, that is, no prior pregnancies, and secondary infertility, referring to infertility following at least one prior conception. And this applies the male partner too which means if he has had a child or gotten pregnant with his current partner or a previous one we call it secondary but if not primary infertility. Infertility is common and affects 10 to 15 percent of reproductive-aged couples. In general, infertility can be attributed to the female partner one third of the time, the male partner one third of the time, and both partners in the remaining one third. This approximation emphasizes the value of assessing both partners before instituting therapy.

What are its causes?

• Female factors
  Ovulatory dysfunction disorders like polycystic ovarian syndrome in which the ovaries become enlarged with fluid filled cysts hindering maturation of the egg. Second is the disruption of the Hypothalamic-pituitary ovarian axis which affects the proper release and action of hormones that are essential for normal pregnancy process. The other is premature ovarian failure which is when the ovaries stop producing egg before the expected time of menopause (45years of age). Other problems can arise from tubal disease too for example Pelvic inflammatory disease caused by Bacteria can cause scarring of the tubes which disables ovum pickup and fertilization. Congenital abnormalities of the female reproductive tract are also worthy of mention.

 

• Male factors
  Erectile dysfunction which especially manifests in patients with hypertension, diabetes mellitus, and neurologic disorders. Problems such as hypospadias which makes it difficult for proper erection of the penis and ejaculation of sperm into the cervix. Prior undescended testis in childhood is also another factor. Testicles need to reside in temperatures below the normal body temperature (37°c) preferably 1.5°c below that to function normally. So in this case when they remain up and undescended the higher temperature suppresses their function, stopping future sperm cell production. Testicular torsion, or testicular trauma will stop the blood supply to the testes which kills them. Sexually transmitted diseases can also predispose to infertility.

 

• Cancer chemotherapy or local radiation treatment, obesity (BMI > 35), Underweight (BMI < 19), Smoking, Alcohol abuse, Illicit drug use are some other factors that can predispose both sexes to infertility.

How can it be treated?

The treatment is also based on which partner is affected. If the male partner is affected the following can be options of treatment

• Lifestyle changes like having sex more often and closer to the time of ovulation, getting regular exercise, reducing alcohol intake or abstaining from using harmful substances such as tobacco.
• Medicines can also improve sperm count and boost the chances of a successful pregnancy.
• Sometimes, surgery may be able to reverse a sperm blockage and restore fertility.

For females partners that have problem conceiving some of the options are the following

• Fertility medicines are the main treatments for infertility that’s due to ovulation trouble. They can help the ovaries release an egg if ovulation is irregular or stops happening.
• Intrauterine insemination (IUI). With IUI, healthy sperm are placed directly in the uterus around the time that the ovary releases one or more eggs to be fertilized.
• Surgery to restore fertility. Some conditions of the uterus like polyps, scar tissue, fibroids can be removed with surgery to restore fertility.

Assisted reproductive technology (ART)

If all of the above remedies can’t bring about conception other newer techniques assisted reproductive technology can be tried.

Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. In vitro fertilization (IVF) is the most common ART technique. Some of the key steps in a cycle of IVF include administering fertility medicines are used to help the ovaries make eggs, removing the matured eggs from the ovaries, fertilizing eggs are with sperm in a dish in a lab, placing the fertilized eggs, also called embryos, in the uterus.

What is the most important thing that everyone should understand?

Of Couples who are trying to conceive and having regular sexual intercourse 50% will conceive in 3 months, 75% in 6 months and more than 85% will be pregnant in 1 year of trying. And you should know that the probability of getting pregnant in the 1^st month (1^st menstrual cycle) is 20-25%. This means only 1 out of 5 or at most 1 out of 4 couples will conceive in the 1^st month of trying. So it is advised to not worry and keep trying for a longer period of time preferably 1 year.

It is recommended to have regular unprotected sexual intercourse for as long as one year, then if still not pregnant visit the doctor’s office. As mentioned above this condition can occur due to problems in both the male and the female partner. So when seeking treatment it is essential that both partners be present and both partners get investigated.

In the hospital both partners will be investigated with simple blood tests, semen analysis for the male, and when further investigations are needed to know the problem imaging studies like Ultrasound, X-ray, CT-scan and MRI may be done to reach to the root cause of the problem. Because this is a complex problem you maybe referred to a Gynecologist or an Infertility specialist. Treatment will be initiated for treatable problems (most of them are treatable). In cases where the cause of infertility is a myoma (benign tumor of the uterine wall) it may be surgically resected. And for untreatable ones the specialist will tell you the different options that are available to you to become a parent, including adoption.

References

1. Williams Gynecology, 4^th Edition
2. World Health Organization (WHO). 2023. Infertility.

https://www.who.int/news-room/fact-sheets/detail/infertility