INFERTILITY

INFERTILITY
The International Council on Infertility Information Dissemination (INCIID) considers a couple to be infertile if:
· they have not conceived after 12 months of unprotected intercourse, or after 6 months if the woman is over 35 years of age. The reduced duration for women over 35 is because there is a rapid decline in fertility after this age and help should be sought sooner.
· there is incapability to carry a pregnancy to term.
Infertility affects approximately 10% of people of reproductive age 15% of couples. Roughly 40% of cases involve a male contribution or factor, 40% involve a female factor, and the remainder involve both sexes.
Healthy couples in their mid-20s having regular sex have a one-in-four chance of getting pregnant in any given month. This is called "Fecundity". There are some health insurance companies that cover diagnosis of infertility but frequently once diagnosed will not cover any treatment costs.
CAUSES OF INFERTILITY
There are two types of infertility, Primary Infertility and Secondary Infertility. Primary Infertility occurs when a couple cannot conceive their first child. Secondary Infertility is where a couple have one child but find it difficult to conceive a second child.
FEMALE INFERTILITY
Factors relating to female infertility are:
· General factors
o Diabetes mellitus, thyroid disorders, adrenal disease
o Significant liver, kidney disease
· Mental factors, mainly Hypothalamic-pituitary in nature:
o These are mainly issues connected to the brain and the portions that stimulate sexual activities and activites in the environment. The pituitary glands secret hormones that promote human growth and sexual functions whilst the hypothalmus regulates activities in the body. The major disfunctions in these two systems lead to the following;
o Kallmann syndrome
o Hypothalamic dysfunction
o Hyperprolactinemia
o Hypopituitarism
· Ovarian factors
o Amenorrhoea: Absence of Mestrual periods
o Polycystic ovarian syndrome: Extremely Irregular Menstrual Cycle
o Anovulation: This reduces levels of a protein in the blood, the sex-hormone binding protein, leading to higher levels of free testosterone circulating in the bloodstream.
o Diminished ovarian reserve: Reduction in certain hormones necessary for pregnancy to occur
o Luteal dysfunction: Dysfunction of a certain cell in the ovary
o Premature menopause
o Gonadal dysgenesis (Turner syndrome): Inability of the ovary to produce eggs
o Ovarian neoplasm: A cancerous growth in the ovary
· Tubal/peritoneal factors
o Endometriosis: a condition in which tissue resembling the lining of the womb, the endometrial tissue, is present in an abnormal position in the body, that is, outside the womb. In endometriosis, tissue resembling the endometrium can be found in various unusual locations in the body, but most commonly in or around the ovaries, vagina, pelvis, abdominal scars, and the small and large intestines.
o Pelvic adhesions: This is where there are fibrous adhesions in the fallopian tubes which prevent the safe passage of the egg.
o Pelvic inflammatory disease (PID, usually due to chlamydia): These are mainly sexually transmitted infections and veneral diseases.
o Tubal occlusion: Closure or blockage of the tube
o Tubal dysfunction: The tube failing to perform its natural function.
· Uterine factors
o Uterine malformations: Increase or abnormal sizes of the uterine usually in the form of tumors.
o Uterine fibroids (leiomyoma)
o Asherman's Syndrome
· Cervical factors
o Cervical stenosis: Abnormal narrowing of the cervical canal or passageway
o Antisperm antibodies: an antibody is any of the millions of normally occurring protein molecules that are produced in the body of cells called lymphocytes and act primarily as a defence against invasion by foreign substances. If an antibody is against sperms, it will destroy all sperms that move in the female reproductive system.
o Insufficient cervical mucus (for the travel and survival of sperm)
· Vaginal factors
o Vaginismus: involuntary spasm of the muscles in the vaginal wall. This occurs when attempts are made to introduce an object into the vagina, for example, during sexual intercourse, insertion of a tampon, or when a doctor or nurse attempts to perform an internal examination. This occurs as a result of emotional conditions for example where a woman has been raped before.
o Vaginal obstruction: This results from the slipping or falling out of certain organs that must be intact to allow conception. There are four possible causes; three of them are natural and one is acquired through veneral diseases like gonorrhoea.
· Genetic factors
o Various intersexed conditions, such as androgen insensitivity syndrome: Where a person has both male and female hormones and characteristics.

MALE INFERTILITY
Factors relating to male infertility include:
· Pretesticular causes
o These are causes out of the testicles.
o Endocrine problems, these are disorders that affect the organs connected to reproduction i.e. diabetes mellitus, thyroid disorders
o Hypothalamic disorders, mental sutuations i.e. Kallmann syndrome
o Hyperprolactinemia
o Hypopituitarism
o Hypogonadism due to various causes
o Drugs, alcohol
· Testicular factors
o Genetic defects on the Y chromosome
§ Y chromosome microdeletions
o Abnormal set of chromosomes
§ Klinefelter syndrome
o Neoplasm, e.g. seminoma Tumors
o Idiopathic failure: Arising from no cause
o Cryptorchidism: Where the testes do not descend to the sac
o Varicocele: Where certain veins in the testicles become enlarge. This can be corrected by surgery.
o Trauma: The result of a bad past experience.
o Hydrocele: Disorder in which serous fluid accumulates in a body sac (especially in the scrotum)
o Mumps: Acute infectious disease caused by virus, similar to the one that affects the salivery glands.
o Testicular dysgenesis syndrome: Infertility within the testicles, thereby producing no sperms at all.
· Posttesticular causes
o This mainly affects the transportation of the semen from the testes out of the penis.
o Vas deferens obstruction
o Infection, e.g. prostatitis
o Retrograde ejaculation: The semen expelled in a frequency and direction that makes it flow to the wrong places.
o Hypospadias: An abnormal condition in males in which the urethra opens on the under surface of the penis
o Impotence: Inability of a man to make love
o Acrosomal defect/egg penetration defect: Acrsome is a process at the anterior end of a sperm cell that produces enzymes to facilitate penetration of the egg. Where this enzyme are non existent in the male sperm, it is impossible to conceive.
· Smoking
o According to a study conducted by the American Society for Reproductive Medicine smoking is one the most prominent factors contributing to low sperm count in men.
Some causes of male infertility can be determined by analysis of the ejaculate, which contains the sperm. The analysis includes counting the number of sperm and measuring their motility (ability of individual sperms to move by themselves and independently) under a microscope:
· Producing few sperm, oligospermia, or no sperm, azoospermia.
· A sample of sperm that is normal in number but shows poor motility, or asthenozoospermia.
In the majority of cases of male infertility and low sperm quality, no clear cause can be identified with current diagnostic methods. It has been speculated that random mutations of the Y chromosome may be an important factor. As the human Y chromosome is passed directly from father to son, it is not protected against accumulating copying errors, whereas other chromosomes are error corrected by recombining genetic information from mother and father. This may leave natural selection as the primary repair mechanism for the Y chromosome. Microdeletions in the Y chromosome have been found at a much higher rate in infertile men than in fertile controls and the correlation found may still go up as improved genetic testing techniques for the Y chromosome are developed. (Existing test kits for Y chromosome microdeletions with PCR markers cover only a tiny fraction of the chromosome's 23 million base pairs and therefore very likely still miss most mutations. The gold standard test for genetic mutation, namely complete DNA sequencing of a patient's Y chromosome, is still far too expensive for use in epidemiologic research or even clinical diagnostics.)
COMBINED INFERTILITY
In some cases, both the man and woman may be infertile or sub-fertile, and the couple's infertility arises from the combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be that each partner is independently fertile but the couple cannot conceive together without assistance.
UNEXPLAINED INFERTILITY
In about 15% of cases the infertility investigation will show no abnormalities. In these cases abnormalities are likely to be present but not detected by current methods. Possible problems could be that the egg is not released at the optimum time for fertilization, that it may not enter the fallopian tube, sperm may not be able to reach the egg, fertilization may fail to occur, transport of the zygote may be disturbed, or implantation fails. It is increasingly recognized that egg quality is of critical importance and women of advanced maternal age have eggs of reduced capacity for normal and successful fertilization.
SYMPTOMS AND SIGNS
MALE INFRETILITY
The history should include prior testicular (penis) insults (torsion, cryptorchidism, trauma), infections (mumps orchitis, epididymitis), environmental factors (excessive heat, radiation, chemotherapy), medications (anabolic steroids, cimetidine, and spironolactone may affect spermatogenesis; phenytoin may lower FSH; sulfasalazine and nitrofurantoin affect sperm motility), and drugs (alcohol, marijuana). Sexual habits, frequency and timing of intercourse, use of lubricants, and each partner's previous fertility experiences are important. Loss of libido and headaches or visual disturbances may indicate a pituitary tumor. The past medical or surgical history may reveal thyroid or liver disease (abnormalities of spermatogenesis), diabetic neuropathy (retrograde ejaculation), radical pelvic or retroperitoneal surgery (absent seminal emission secondary to sympathetic nerve injury), or hernia repair (damage to the vas deferens or testicular blood supply).
FEMALE INFERTILITY
Female infertility occurs when the woman does not conceive after one year of attempting to become pregnant. Other signs and symptoms depend on the underlying cause of the woman's infertility.
DIAGNOSIS AND TESTS
MALE INFERTILITY
The diagnosis of infertility begins with a medical history and physical exam. The provider may order blood tests to look for hormone imbalances or disease. A semen sample may be needed. The volume of the semen is measured, as well as the number of sperm in the sample. How well the sperm move is also assessed.
The cornerstone of the male partner evaluation is the history. It should note the duration of infertility, earlier pregnancies with present or past partners, and whether there was previous difficulty with conception.
A complete examination of the infertile male is important to identify general health issues associated with infertility. For example, the patient should be adequately virilized; signs of decreased body hair or gynecomastia may suggest androgen deficiency.
The scrotal contents should be carefully palpated with the patient standing. As it is often psychologically uncomfortable for young men to be examined, one helpful hint is to make the examination as efficient and as matter of fact as possible.
The peritesticular area should also be examined. Irregularities of the epididymis, located posterior-lateral to the testis, include induration, tenderness, or cysts.
FEMALE INFERTILITY
Diagnosis of infertility begins with a medical history and physical exam. The healthcare provider may order tests, including the following:
· an endometrial biopsy, which tests the lining of the uterus
· hormone testing, to measure levels of female hormones
· measurements of thyroid function (a thyroid stimulating hormone(TSH)level of between 1 and 2 is considered optimal for conception)
· laparoscopy, which allows the provider to see the pelvic organs
· measurement of progesterone in the second half of the cycle to confirm ovulation
· Pap smear, to check for signs of infection
· pelvic exam, to look for abnormalities or infection
· a postcoital test, which is done after sex to check for problems with secretions (not commonly used now because of test unreliability)
· special X-ray tests
Diagnosis of infertility should be made by physicians who are fellowship trained as reproductive endocrinologists. Reproductive Endocrinologists are usually Obstetrician-Gynecologists with advanced training in Reproductive Endocrinology & Infertility (in North America). These highly educated professionals and qualified physicians treat Reproductive Disorders affecting not only women but also children, men, the postmenopausal woman. These specialized professionals treat primarily, infertility for both sexes.
Prospective patients should note that reproductive endocrinology & infertility practices do not see women for general maternity care. The practice is primarily focused on getting their patients pregnant.
TREATMENT
· Fertility medication which stimulates the ovaries to "ripen" and release eggs (e.g. clomifene citrate, which stimulates ovulation)
· Surgery to restore patency of obstructed fallopian tubes (tuboplasty)
· Donor insemination which involves the woman being artificially inseminated with donor sperm.
· In vitro fertilization (IVF) in which eggs are removed from the woman, fertilized and then placed in the woman's uterus, bypassing the fallopian tubes. Variations on IVF include:
o Use of donor eggs and/or sperm in IVF. This happens when a couple's eggs and/or sperm are unusable, or to avoid passing on a genetic disease.
o Intracytoplasmic sperm injection (ICSI) in which a single sperm is injected directly into an egg; the fertilized egg is then placed in the woman's uterus as in IVF.
o Zygote intrafallopian transfer (ZIFT) in which eggs are removed from the woman, fertilized and then placed in the woman's fallopian tubes rather than the uterus.
o Gamete intrafallopian transfer (GIFT) in which eggs are removed from the woman, and placed in one of the fallopian tubes, along with the man's sperm. This allows fertilization to take place inside the woman's body.
· Other assisted reproductive technology (ART):
o Assisted hatching
o Fertility preservation
o Freezing (cryopreservation) of sperm, eggs, & reproductive tissue
o Frozen embryo transfer (FET)
· Alternative and complimetary treatments
o Acupuncture Recent controlled trials published in Fertility and Sterility have shown acupuncture to increase the success rate of IVF by as much as 60%. Acupuncture was also reported to be effective in the treatment of female anovular infertility, World Health Organisation, Acupuncture: Review and Analysis of Reports on Controlled Trials (2002).
o Diet and supplements
o Healthy lifestyle
PREVENTION AND EXPECTATION
MALE INFERTILITY
Some cases of male infertility may be avoided by doing the following:
· Avoid drugs and medications known to cause fertility problems, like steriods and some antifungal medications.
· Avoid excessive exercise.
· Avoid exposure to environmental hazards such as pesticides.
· Avoid frequent hot baths or use of hot tubs.
· Avoid tight underwear or pants.
· Eat a diet with adequate folic acid, and vitamine C and Zinc loaded food.
· Get early treatment for sexually transmitted diseases.
· Have regular physical examinations to detect early signs of infections or abnormalities.
· Keep diseases, such as diabetes and hypothyroidism, under control.
· Practice safer sex to avoid sexually transmitted diseases.
· Take a lycopene supplement.
· Wear protection over the scrotum during athletic activities.
FEMALE INFERTILITY
Some cases of female infertility may be prevented by taking the following steps:
· Avoid excessive exercise.
· Avoid smoking.
· Control diseases such as diabetes and hypothyroidism
· Follow good weight management guidelines.
· Get early treatment for sexually transmitted diseases.
· Have regular physical examinations to detect early signs of infections or abnormalities.
· Limit caffeine and alcohol intake.
· Use birth control to prevent unwanted pregnancy