What is infertility?

Infertility is a disease of the reproductive system impairing the body’s ability to reproduce (having a healthy baby). When a couple have tried to conceive for more than one year (more than 6 months if the woman is more than 35 years) they are generally advised to seek medical help from an expert. To conceive a child is a complicated process involving many different factors from the quality and quantity of the gametes (sperm in men and eggs in women) to healthy and functional physiology of the reproductive organs/tissues as well as a functional hormone balance in both women and men. Infertility affects men and women equally. Approximately 1 couple in 8 have problems to conceive (difficulties getting pregnant or sustaining a pregnancy). Roughly 1/3 of the infertility is attributed to the female partners and 1/3 to the male partners respectively. The last 1/3 is considered to be caused by a combination of problems in both partners, or the medical issues can not be detected as of now.

For how long should we try to conceive before we reach out to a specialist?

If you are under the age of 35 most fertility clinics suggest that you to try to get pregnant for at least 12 months. However, if you are over the age of 35 or if you do not have regular menstrual cycles the general advice is that you should seek help from a specialist (reproductive endocrinologist) after 6-month period of trying to conceive.

 

Diagnosis

After a couple have contacted a fertility clinic the physician will most often conduct a physical examination of both the woman and the man to determine the state of health and to evaluate any physical disorders that may be causing the fertility problems. In addition, there is often a short interview/discussion with the couple where the doctor is going over the couple’s sexual habits and history in order to determine whether there might be any factors in their intimate relationship that could be an issue for the couple’s success to conceive.

Very often the couple will then be recommended to take more specific tests in order to find out more about the fertility status for the woman and the man respectively. For women these tests most often include x-ray of the fallopian tubes and uterus as well as hormone analysis of certain hormones at specific days of her menstrual cycle. The latter to determine whether she has any problems with her ovulation since this is the major cause of infertility in women. For men, semen analysis is usually the next step. This since problems with sperm (production and/or delivery) is the major infertility problem in men.

 

Different causes of infertility – Women

Problems with Ovulation or Menstrual Cycle: About 25% of all female infertility problems are due to irregular or abnormal ovulationIrregular periods is another cause in women. If you do have irregular menstrual cycles you may not ovulate. Irregular periods can be caused by  different conditions such as:

  • Polycystic Ovary Syndrome (PCOS): This is the most common hormonal endocrine disorder in women. The main underlying problem with PCOS is a hormonal imbalance which can interfere with normal ovulation. Women who suffers from PCOS produce more androgens (male hormones that are also produced in females) than normal. High levels of androgens affect the development and release of eggs during ovulation. Some common signs and symptoms of PCOS are irregular menstrual cycles, weight gain, excess hair growth on face and body (Hirsutism), darkened patches of skin, infertility, insulin resistance, multiple cysts on the ovaries (“string of pearls pattern”), pelvic pain. The cause of PCOS is still unknown and most experts think there are several factors responsible where genetics is one of the key factors. PCOS is the most common cause of female infertility (responsible for 70% of infertility issues in women who have difficulty ovulating).
    • Fertility medications: Lack of ovulation is usually found in women suffering from PCOS and therefore medication that stimulates ovulation is normally the first choice.
      • Clomiphene (also known as Clomid): A typical first choice to stimulate ovulation. It is an oral drug and both dosage and treatment protocols may vary depending on your doctor.
      • Letrozole: This is also an oral drug that works similar to Clomiphene and it  is also often choose as the first medication to stimulate ovulation. Letrizole should also be determined by your practitioner and dosage and protocols may vary.
      • Gonadotropins: Follicle stimulating hormone (FSH) and Luteinizing hormone (LH) are normally both released from the pituitary gland in the brain and are both controlling the ovaries. FSH activates one or more of the immature eggs in the ovary causing them to develop and mature forming a follicle. LH triggers the follicle to release the ripe egg when it is fully matured and produce progesterone. Gonadotropins are injected subcutaneously (under the skin). This medication requires careful monitoring. This in order to prevent unwanted hyperstimulation of the ovary which may cause a higher risk of multiple pregnancies (twins, triplets, quadruplets etc) and also hyperstimulated ovaries become enlarged and cystic endangering the woman’s health.

                    More about Clomiphene and Letrozole can be read here.

  • Diminished Ovarian Reserve (DOR): Ovarian reserve is the pool of eggs that are present in the ovaries. Females are born with about two millions eggs, but the majority of them will not develop but instead decay and at the time of puberty there are approximately 250,000 – 500,000 eggs left. At the age of 37 a woman normally has an ovarian reserve of 25,000 eggs and at menopause this number has declined to around 1000. There is not only the number of eggs that are declining with age but also the quality. Egg quantity and quality normally starts to decline in the early 30s and this decline is escalating further when the woman reach her late 30s to early 40s.  DOR occurs when the ability of ovary to produce eggs is reduced because of congenital, medical, surgical or unexplained causes.
    • Diagnosis: Several tests can be done to assess the functional reserve of the ovary.
      • Blood test obtained on Day 2 or Day 3 of the menstrual cycle, measuring the hormone levels of FSH and Estradiol. Fluctuation in the normal baseline of these two hormones indicate a declining ovarian reserve.
      • Levels of Anti-Mullerian Hormone (AMH) can also be analyzed with a simple blood test. Levels of AMH correlates with fertility potential since this hormone generally reflects the number of eggs in the ovaries. AMH levels normally falls months to years before any abnormalities in FSH and Estradiol are detectable. This test is normally performed in combination with FSH/Estradiol blood testing and an assessment of the number of visible antral follicles in the ovaries (transvaginal ultrasound).
    • Fertility Treatments: No treatments exist that can slow down or prevent ovarian aging. If a woman is diagnosed with DOR, all treatments will be designed to speed up the time to conception trying to prevent loss of more eggs (quantity and quality). Normally fertility treatments start as soon as possible. Eggs could also be cry-preserved (frozen) for use in the future if the woman can not undergo fertility treatment in a very near future. When undergoing IVF treatment a patient with DOR will be given a higher dose of ovarian stimulation regimens to maximize the number of eggs harvested. If this stimulation does not work, women with DOR are often recommended to use donor eggs from a younger woman.
  • Premature Ovarian Failure (POF): This is a condition also called Premature Ovarian Insufficiency (POI). It refers to a loss of normal function of the ovaries before the age of 40 and it affects 1 in 100 women. Women who suffers from POF often have irregular or only occasional periods for years. They may however, have a small chance to become pregnant without help from a clinic (10% of women with POF conceive on their own), which is not the case in women who suffer from premature menopause.
    • Diagnosis: A blood test is performed checking whether the ovaries are producing estrogen and  whether the pituitary gland is producing FSH (follicle stimulating hormone) and LH (Luteinizing hormone). A woman with elevated FSH and LH but who’s ovaries are not producing estrogen will be diagnosed with POF. Often the the ovaries are also evaluated with a transvaginal ultrasound. In POF patients, the ovaries are usually small and there are few follicles seen.
    • Fertility Treatments: Most women suffering from PCOS will not become pregnant with their own eggs, but are recommended to undergo IVF treatment using donor eggs from another woman.

Problems with the Fallopian Tubes: A woman can suffer from different abnormalities in her fallopian tubes; open, blocked or swollen (Tubal Patency). If a woman can not conceive because of issues related to her fallopian tubes, she is suffering from tubal infertility. Tubal infertility includes not only blockage but also other tubal damage that can prevent fertility such as problems with “egg pickup” during ovulation.

  • Blocked and/or Swollen Fallopian Tubes (tubal occlusion, hydrosalpinx): If the fallopian tube is blocked at the end of the tube away from the uterus it is called distal tubal occlusion. If distal tubal occlusion occurs, the fallopian tube could be dilated with fluid (hydrosalpinx), meaning that the fluid secreted by the cells inside the tube cannot get out so instead this fluid builds up and dilates the tube. A swollen fallopian tube can be confused on ultrasound as an ovarian cyst. Hydrosalpinx is often caused by an infection such as pelvic inflammatory disease (PID) which causes the tube(s) to become inflamed. Other causes can be sexually transmitted infections , endometriosis of previous surgery (mainly on the tube). The tube(s) often stays blocked with residual fluid inside even after the pelvic inflammation is healed. Continued build up of fluid over time will result in further dilation of the tube(s) and various sizes of hydrosalpinges.
    • Diagnosis: There are three ways to evaluate the health of the fallopian tubes.
      • Hysterisalpingogram (HSG) (X-ray): A special liquid is injected into the uterus through the cervix (neck of the womb). This liquid will show up on an x-ray. If the fallopian tube is open the liquid will flow freely in the tube until it reaches the pelvic cavity. However, if there is a blockage in any or both of the fallopian tube(s) the liquid will be trapped.
      • Ultrasound: More severe hydrosalpinx can be detected via ultrasound where the tube(s) appears enlarged.
      • Laparoscopy (surgery): A special telescope is inserted through a small opening in the belly to look at the uterus and fallopian tubes. Usually a dye is also inserted through the cervix into the uterus and fallopian tubes to help detect any blockage or other abnormalities.
    • Fertility Treatment: If both fallopian tubes are blocked (bilateral tubal occlusion) the woman will need to undergo IVF treatment of tubal reconstructive surgery. However, tubal surgery is not performed as much now as it was in the 1980s and 1990s. This because IVF treatments have much higher success rates today, and the risks for ectopic pregnancies are lower.

Different causes of infertility – Men

Traditionally, infertility have been thought of as a female problem, probably because it is the woman who becomes pregnant and carries the baby until delivery. However, infertility affects men and women equally and the awareness of male infertility is rising. There are various factors that influence men’s fertility, all of them however will affect the production and/or the delivery of sperm which both are complex processes involving hormone levels, genetics as well as healthy physiology of the male genitalia. Infertility in men is normally due to low sperm production, abnormal sperm function or blockages that prevent the delivery of sperm. Furthermore, external factors such as heat can also affect sperm quality and quantity. It is well known that men who experience problems conceiving should try to avoid long hot showers, baths or visits to the sauna if possible.

Sperm

Sperm cells are the male gametes. In order for fertilization to occur a male gamete has to fuse with a female gamete (egg cell). Male infertility usually occurs because of sperm that are abnormal, because of inadequate numbers of sperm, or problems with ejaculation. Sperm can be considered abnormal for two possible reasons: unusually short life span of the sperm and/or low mobility.  Like for women, male fertility is a complex process which includes:

  • Production of healthy sperm. Initially, this involves the growth and formation of the male reproductive organs during puberty. At least one of your testicles must be functioning correctly, and your body must produce testosterone and other hormones to trigger and maintain sperm production.
  • Sperm have to be carried into the semen. Once sperm are produced in the testicles, delicate tubes transport them until they mix with semen and are ejaculated out of the penis.
  • There needs to be enough sperm in the semen. If the number of sperm in your semen (sperm count) is low, it decreases the odds that one of your sperm will fertilize your partner’s egg. A low sperm count is fewer than 15 million sperm per milliliter of semen or fewer than 39 million per ejaculate.
  • Sperm must be functional and able to move. If the movement (motility) or function of your sperm is abnormal, the sperm may not be able to reach or penetrate your partner’s egg.

The most common male infertility factors are azoospermia (no production of sperm cells or normal sperm production but in the presence of obstruction) leading to a complete absence of sperm cells in the ejaculate, and oligospermia (very few sperm cells are produced) resulting in a low sperm count (<20 million/ml, whereas more than or equal to 20 million/ml is considered normal).

  • Azoospermia: Approximately 1% of the male population is affected by azoospermia and about 10% of men who are evaluated for infertility. In patients with no sperm production, hormonal analysis will often show an elevated level of FSH with normal testosterone and estradiol levels. Fertility Treatment: Sperm can be retrieved by TESE (Testicular Sperm Extration) where sperm is extracted with a testicular biopsy. IVF treatment can then be performed where assisted reproductive procedure ICSI (Intracytoplasmatic Sperm Injection) is used to “inject the sperm directly into the egg cell”.
  • Oligospermia: Fewer sperm cells than normal are found in the ejaculate. It can be caused by many factors including obstruction of the normal flow of sperm due to conditions such as testicular trauma, scarring from either surgery or infection and sexually transmitted diseases. Another cause of oligospermia is of course vasectomy. Oligospermia can also be caused of a decrease of sperm production. This could be due to hormonal disorders, varicoceles (swelling of the veins that drain the testicle), disease of the testicles and obesity. Treatment varies depending on the type and the severity of oligospermia and may include losing or gaining weight, improving the diet, reducing alcohol intake, stop smoking, avoiding hot baths/showers and tight underwear. Medications that might be used include fertility drugs, vitamins E and C, antioxidants and hormone therapy. Fertility Treatment: Also for patients suffering from oligospermia TESE can be performed, all depending on the recommendations from the physician.

 

 

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