Fertility is the natural
capability to produce offspring. It explains the whole process
from gamete
production, fertilization and carrying a pregnancy to term. Simply it explains
the complete process of producing a live offspring. On the other hand fecundity
means the potential for reproduction or the ability to get pregnant. Fertile
couples are invariably fecund and the reverse is not possible always. Lack of
fertility is referred as infertility and lack of fecundity (the basic ability
in the process of producing a live offspring) is called sterility.
World Health Organization defines
infertility as a DISEASE (certain insurance companies do not accept claims
though) of the reproductive system defined by the failure to achieve a clinical
pregnancy after 12 months or more of regular unprotected sexual intercourse.
Infertility generates disability.
Infertility in women was ranked the 5th highest serious global disability.
Worldwide one out of every seven couples is infertile. In Sri Lanka 10% of the
couples are infertile. In 50% of these cases male is the factor while in one
third woman is the factor.
The reasons for infertility are
described under five categories (See the Table)
Causes for Infertility
Primary (%)
|
Secondary (%)
|
|
Anovulation (Failure to produce mature eggs)
|
20
|
15
|
Male factors
|
25
|
20
|
Fallopian tube problems
|
15
|
40
|
Endometriosis
|
10
|
5
|
Unexplained
|
30
|
20
|
Although single category may be
the only reason for a given couple’s infertility, some of these categories may
coexist in the same couple (i.e. anovulation and male factor). Generally
likelihood of a spontaneous live birth in an infertile couple is strongly
influenced by the age of the female, duration of infertility, previous
pregnancies, and cause of infertility. Unexplained infertility has the best
outcome.
Anovulation or failure to release
mature eggs is one of the commonest causes of infertility. Among conditions
causing anovulation, Polycystic Ovarian Syndrome (PCOS) would be the commonest.
It is characterized by irregular menstrual cycles, androgen (male hormone)
excess and Ultrasound evidence of polycystic ovaries.
PCOS is commonly seen among young
women in a prevalence of 5% – 7%. It manifests commonly as irregular menstrual
cycles. Not only PCOS possess gynecological implications, but also those
related to other systems too. They are obese and tend to get metabolic syndrome
and diabetes. They are good candidates for deranged lipid metabolism.
Figure 1 Abnormal Hair
Growth in the Face Seen in a Woman with PCOS
Endometriosis by far
one of the commonest problems among females. It also found in younger females.
The key feature is presence of endometrial tissue (the inner lining of the womb
that sheds during menses) outside the uterine cavity. This ectopic tissue too
undergoes cyclical bleeding due to hormonal changes and find no way to be
drained out hence get collected.
These internal menstrual
collections adhere the surrounding structures together. This causes an intense
pain during cycles – sometimes outlasting the duration of menses. Endometriosis
associates with infertility in various ways by interfering egg maturation,
ovulation, gamete (eggs and sperms) transfer and implantation (‘seeding’ of the
fertilized egg in the womb).
Fallopian tubes are important
transporters contributing to fertility. They involved in transfer of gametes
(eggs and sperms towards each other) and transportation of fertilized egg in to
womb. In fertility treatment tubal disease exerts a great challenge.
Although infertility has been
defined with one year, a couple has to be investigated earlier if they have any
pre-existing disease or the female is over 35 years. Extensive clinical
assessment of the couple has to be carried out. Baseline investigations will be
a Seminal Fluid Analysis (SFA) and Trans Vaginal Ultrasound (TVS) Scan of the
female. SFA though a baseline investigation provides a big picture about the
male partner; several parameters related to the quality of sperms will be
assessed according to a standard criteria issued by the WHO.
Figure 2 Normal Hysterosalphyngogram
Hysterosalphyngogram
(HSG) and Diagnostic Laparoscopy and Dye Test (Laparoscopy + DT) will be used
depending on each situation to assess the patency of Fallopian tubes while
latter provides a comprehensive image (under direct vision) about the female
reproductive system. Various hormonal assays are available to investigate the
problems with internal signaling pathways related in reproduction and menstrual
cycle. Blood tests as well as urinary dipstick tests are available to correctly
find out the time of ovulation. As a habit all females seeking treatment for
infertility are asked to maintain a menstrual diary where they have to document
the details of each day of their cycle. As a standard first day of the period
(first day of bleeding) will be taken as Day 1 of the cycle and following days
numbered accordingly.
Ovarian reserve is one of the
major concerns when managing couples with infertility. Unlike men women are
destined to have a limited period of fertility. They are provided with limited
number of eggs, few of which are disposed in each cycle. Therefore ovarian
reserve – in other words the number of retrievable eggs for fertilization has
major implications on the success rate of infertility treatment. The main factor
determining ovarian reserve is the age of the female.
Figure
1- Laparoscopic Diagnostic Test Showing Free
Spill of the Dye
All infertility
treatment is focused on utilizing this ovarian reserve effectively in order to
provide couple with a healthy pregnancy. Treatment options are enormous. First
of all identified underlying diseases contributing to the condition has to be
treated. Obese females are encouraged to reduce their weight which will
invariably return their regular cycles hence fertility. Few tablets are
available in a basic treatment called ovulation induction where doctors
stimulate ovaries to produce good quality eggs as required. Seminal fluid (the
liquid containing sperms) is processed in laboratory setup so the quality of
the sperms is improved, will be used to be deposited inside the womb (Intra
Uterine Insemination – IUI). When a male partner cannot produce a sample with
adequate amount of sperms donor samples can be used orIUI.
Figure
4 ICSI One of the IVF technologies in which a selected sperm is directly
injected into an ovum (egg)
Invitro
Fertilization (IVF) has shown some light to many of bereft couples. This
technique involves the artificial combination (in a laboratory setup) of sperms
and eggs and implanting the embryos formed thereafter inside the female’s womb.
Various methods are available under this category. Women are advised to take
folic acid throughout and have Rubella vaccination (if it has not been given
when schooling) six months prior to the initiation of treatment.
Key Facts
- · Infertility/Subfertility is a Disease
- · Both Males and Females equally contribute for its causation
- · Female’s age is the most important factor in determining the success rate of treatment
- · Most couples will benefit from simple treatment option
Dr Nalin Abeysinghe MBBS (Sri Jayewardenepura),
Medical Officer in Obstetrics and
Gynaecology,
Sri Jayewardenepura General Hospital,
Nugegoda.
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