Infertility


What is infertility?

The inability to conceive after trying for a period of one year or more is defined as infertility. Most couples (about 84 out of every 100) who have regular sexual intercourse (that is, every 2 to 3 days) and who do not use contraception will get pregnant within a year. About 92 out of 100 couples who are trying to get pregnant do so within 2 years.


When should I see an infertility specialist?

If you are less than 35 years of age, have regular periods and both of you have no medical problems, you can get yourself evaluated after one year of trying. If everything looks normal, it would be reasonable to try for another year before starting treatment. If you are older than 35 years, it would be best to get evaluated after 6 months of trying.


What causes infertility?

In men, the problem is usually because of low numbers or poor quality of sperm. Inability to have a proper intercourse is an uncommon but important cause. A woman may have fertility problems because she may not produce eggs regularly (anovulation), if the eggs are less in number (decreased ovarian reserve) or because her fallopian tubes are damaged or blocked and the sperm cannot reach her eggs. For nearly one third of people, no reason can be found for their problem. This is known as unexplained fertility problems.


Does smoking or alcohol use matter?

Smoking is likely to reduce fertility in women and is harmful to the baby if you are pregnant. For men, there is a link between smoking and poorer quality of sperm. If infertility is mainly due to poor sperm count or quality, it is very important to stop smoking completely and avoid all forms of tobacco. For women it is best to avoid alcohol or have no more than 1 or 2 units of alcohol once or twice a week. Drinking excessive amounts of alcohol can affect the quality of a man's sperm. It is best to drink less than 12 units per week. You can calculate your alcohol intake here [https://www.drinkaware.co.uk/understand-your-drinking/unit-calculator]


What about body weight?

The range of healthy weight is defined by a measurement known as the body mass index (BMI). You can calculate your BMI here.

You are healthy if your BMI is between 20 and 25.

Women who have a BMI of more than 29 can take longer to get pregnant than women whose weight is normal. If you are overweight (a BMI of more than 29) and you have irregular periods, or no periods at all, losing weight may increase your chances of getting pregnant. If your weight gets down to the normal range, your ovaries may start working again. Women who take part in group exercise and diet programmes have a better chance of loosing weight and getting pregnant than those who try to lose weight on their own. If you are underweight (you have a BMI under 19) and you have irregular periods, or no periods at all, you may find that if your weight gets back up to the normal range your ovaries will start working again, and so improve your chances of getting pregnant. If you are a man and you are overweight (a BMI of more than 29), your fertility is likely to be lower than normal.


Poor ovarian reserve

Background

The ovary is generally thought of as an ‘egg bank’ from which the woman draws during her reproductive life. While each month one egg (oocyte) is released by ovulation; about one thousand additional eggs are lost by destruction. Few if any eggs are replenished during the reproductive years. Thus with advanced maternal age the number of eggs that can be successfully recruited for a possible pregnancy declines. Attempts have been made to assess the number of potential useful oocytes in a noninvasive way.

How to test for ovarian reserve

Hormonal Markers

FSH is a hormone secreted by the pituitary gland and indicates the reserve of the ovary. The basal level of Follicle stimulating Hormone (FSH) done on day 1 to day 3 of the period is a better predictor of ovarian reserve than age. The FSH varies from cycle to cycle and thus we can get a variable results in the prediction of ovarian reserve

Ultrasound Markers

Ultrasound of the ovaries which detects the small follicles is an accurate indicator of ovarian reserve. An antral follicle count of less than 5 predicts an unfavorable response.

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This test is dependant on the skill of the scanning person and may differ.

Anti- Mullerian Hormone

AMH is the more accurate test for predicting ovarian reserve The hormone AMH, which is made by the ovarian follicle containing the egg, can tell us how a woman’s ovaries can respond to fertility drugs.

In young women many eggs start to grow each day and quite large numbers reach the final stages of development, where they can respond to fertility drugs. These women have high AMH values. In older women, there are fewer eggs left in the ovary and few will reach these latter stages of development. The blood level of AMH can tell us how many follicles (eggs) are likely be available.

Knowledge of how patients’ ovaries will respond to the hormone injections of a treatment ‘cycle’ is a very important part of fertility treatment. An excessive response to the hormone drugs increases the chances of suffering the dangerous condition of ‘ovarian hyper stimulation syndrome’ (OHSS), while an inadequate response is distressing for patients going through 2 to 3 weeks of daily injections and resulting in no eggs or a sub-optimal number of eggs at egg collection. Both these scenarios are experienced too frequently when we do not know how a patient is likely to respond. Unfortunately, we cannot avoid either of these end-points completely, but we can now use a test to allow us to modify our approach, resulting in a reduced incidence of both.

Modification of treatment strategies

The ovarian assessment allows us to use different treatment strategies for different patients, taking into account their likely response to fertility drugs, thereby increasing treatment safety and pregnancy rates.

When the AMH concentration is high, it indicates a risk of OHSS when traditional treatment methods are used. We can therefore modify our strategy to accommodate this. The AMH test is often increased in polycystic ovarian syndrome, and is beneficial in diagnosing polycystic ovaries from multi cystic ovaries

When the AMH concentration is low, it indicates that the response to traditional treatment methods will be below average, and therefore the chances of success in IVF / ICSI will be reduced. This is common in older women (>37 years), where it is well known that success rates are reduced. However, the predictive value of AMH is considerably better than using a patient’s age.

General implications of low AMH value

It is possible for a woman to maintain a normal menstrual pattern for many years after her AMH value is recorded as ‘low’. This is because regular ovulation can be maintained with only a couple of follicles reaching these responsive stages of development each week. However, this is too small a number to allow a response in the number of eggs required for a treatment cycle.

This allows us to use a more individualised treatment regimen which should ultimately result in higher fertilisation and pregnancy rates for selected patients. It should also reduce the cost of treatment for selected patients.


PCOS

What are polycystic ovaries?

Women with polycystic ovaries have ovaries which are larger in size and contain more than the usual number of follicles. ‘Follicles’ are tiny round structures normally seen in the ovary – each follicle contains an egg. Polycystic ovaries are common and are seen in 1 in 5 women.

What is polycystic ovarian syndrome?

PCOS (polycystic ovarian syndrome) occurs in around 5% of women with polycystic ovaries. Women with PCOS may have the following problems

  • Irregular menses
  • Prolonged and irregular bleeding
  • Excessive body hair
  • Acne (pimples)
  • Oily skin
  • Dark skin on the back of the neck
  • Difficulty becoming pregnant
  • Excessive body weight and difficulty in loosing it

How is PCOS diagnosed?

PCOS is diagnosed when a woman has some of the above mentioned problems. Your doctor might need to perform an ultrasound scan and perform certain blood tests to confirm the diagnosis.

What causes PCOS?

The exact cause of PCOS is not known. PCOS tends to run in families. Abnormalities in the way certain hormones are produced in the body are likely to have an important role. Rapid weight gain in women with polycystic ovaries might bring out or worsen symptoms of PCOS.

Can PCOS be cured?

PCOS cannot be cured. By maintaining a healthy lifestyle, the symptoms of PCOS can be kept under control. Your doctor might need to prescribe medications to help you regularise your periods or to help you become pregnant.

What are the long term risks?

Women with PCOS have a higher risk of developing diabetes later in life and during pregnancy. This risk is higher if your parents have diabetes. There is growing evidence that there is a increased risk to develop hypertension (high blood pressure), dyslipidemia (high levels of bad cholesterol) and heart disease. Women with PCOS who have infrequent periods, have a higher chance of developing abnormal thickening of the inner lining of the uterus and rarely endometrial cancer.

Infertility and PCOS

Women with PCOS might take longer to become pregnant and might need medications to help them conceive.

What can I do?

Symptoms of PCOS can be kept under control by –

  • Maintaining a normal body weight – your BMI should be between 20 and 25.
  • A balanced diet with adequate fruits, vegetables and fibre. Avoid excessive oil, sugar and salt.
  • Exercise for 30 minutes three to four times a week.

Regular health check ups – get your blood pressure and blood sugar checked every year. Additional tests like blood cholesterol and ultrasound scan may be performed if indicated.


Endometriosis

What is endometriosis?

Endometriosis is a condition where tissue similar to the lining of the uterus (which should only be located inside the uterus) is found elsewhere in the body. Endometriosis can be found anywhere in the pelvis, but are most commonly seen behind the uterus and on the ovaries.

What are the symptoms of endometriosis?

The most common symptom of endometriosis is pelvic pain. The pain is often worst during the time of periods; however a woman with endometriosis may also experience pain at other times. This pain can sometimes be quite severe and unbearable. Pain during and after sex might be present. Some women may have loose stools or constipation, especially during periods. The other well known symptom associated with endometriosis is infertility. This occurs in 30-40% of women with endometriosis.

What causes endometriosis?

Several different hypotheses have been put forward to explain the cause of endometriosis. Unfortunately, none of them have been proven. Thus, the cause of endometriosis remains unknown.
How is endometriosis diagnosed?
Your doctor may diagnose endometriosis if any of the above mentioned symptoms are present. An ultrasound scan helps confirm the diagnosis if cysts due to endometriosis (chocolate cysts) are present. A laparoscopy is often required to diagnose and treat endometriosis.

How is endometriosis treated?

There are different ways to treat endometriosis. This will depend on how extensive the disease is and what symptoms it is causing. Treatment options include

Pain killers
Hormonal therapy may include birth control pills, progestins and GnRH-analogues
Surgery is required to confirm the diagnosis and treat the problem. Surgery is usually by laparoscopy, though open surgery is needed in rare cases for extensive disease


Fibroids

What are fibroids?

Fibroids are benign (non-cancerous) tumours of the uterus (womb). They are also known as myomas. They are growths of smooth muscle and fibrous tissue. The size of fibroids can vary from as small as a pea to that of a melon. At least one in five women develops a fibroid at some stage of their life, usually between the ages of 30-50 years.

What are the types of fibroids?

Fibroids are named according to where they are found in the uterus. There are four types :-

  • Intramural fibroids are found in the wall of the uterus and are the most common type of fibroids found in women.
  • Subserosal fibroids are found growing outside the wall of the uterus and can become very large. They can also grow on stalks (called pedunculated fibroids).
  • Submucosal fibroids are found in the muscle beneath the inner lining of the wall of the uterus. are found in the muscle beneath the inner lining of the wall of the uterus.
  • Cervical fibroids are found in the wall of the cervix (neck of the uterus).

What are the symptoms of fibroids?

Many women with fibroids show no symptoms and are unaware that they have fibroids. However, if symptoms develop, you may experience one or more of the following:

  • eavy or painful periods in some cases this can lead to anaemia (low blood haemoglobin levels)
  • Discomfort, or swelling, in your lower abdomen, particularly if your fibroids are large,
  • Backache, or pains in your legs,
  • Urinating frequently, usually if your fibroids are pressing on your bladder,
  • Constipation which can be caused by the fibroids pressing on your rectum and
  • Pain or discomfort during sex this is usually if your fibroids are growing near your vagina (or lower part of your cervix).
  • Infertility

In some cases, you may have repeated miscarriages or infertility problems. Very rarely, fibroids can cause problems during pregnancy and labour.

How are fibroids diagnosed?

As fibroids rarely have symptoms, they are often found during a routine gynaecological (vaginal) examination.
If fibroids are suspected, an ultrasound scan can be used to confirm a diagnosis. Less commonly, a MRI Scan may be used if there are multiple fibroids, the uterus is very large or some other problem is being suspected.

What causes fibroids?

Fibroids are smooth muscle growths that occur between the ages of 16 and 50. During this time, the levels of female hormones (estrogen and progesterone) are at their highest. Fibroids tend to swell when estrogen levels are particularly high, for example, during pregnancy. They are also known to shrink when oestrogen levels are particularly low, such as after a woman has experienced the menopause. However, the exact cause of fibroids is still unknown.

How can fibroids affect infertility?

Infertility is more common in women with large fibroids as they can interfere with the fertilised egg attaching to the lining of your womb. If you have a submucosal type of fibroid (growing outside the wall of your womb), this could also affect the shape of your womb, making it harder for you to conceive (get pregnant).

How are fibroids treated?

If you do not have any symptoms from your fibroids, treatment may not be necessary and a regular follow up is advised. After the menopause, fibroids often shrink, and your symptoms will either disappear or ease slightly.

Treatment with medication

Medicines do make the fibroids disappear, but can help with relieving certain symptoms. You doctor might give you medications which reduce the amount of bleeding and pain you have during your periods. If your haemoglobin levels are low, iron tablets would be prescribed.

Injections which contain a hormone medicine called gonadotropin releasing hormone agonist (GnRHa) may be given to reduce the size of the fibroid. Unfortunately, its effect is temporary and you cannot use it for a long duration.

Contraceptive pills and the Mirena coil can be used to reduce symptoms related to the fibroids, but cannot be used if you are trying for a pregnancy.

Surgical procedures

Surgical procedures for treating fibroids are usually considered if medications are ineffective. There are a number of different surgical procedures that can be carried out to treat fibroids. Common surgical procedures that are used to treat fibroids include:

Hysterectomy involves surgery to remove the uterus.

Myomectomy involves surgery to remove the fibroids from the uterus. A myomectomy is an alternative to having a hysterectomy, particularly for women still wishing to have children. Both hysterectomy and myomectomy are performed using laparoscopic surgery at this centre

Are there any long term risks?

Very rarely, in around one in 1,000 cases, a cancer called leiomyosarcoma may begin to develop in the fibroids.


Men and infertility

Infertility may be due to problems in either the male or female partner. Male problems may be contributory in 30% to 40% of infertile couples. The initial screening evaluation of the male partner includes a history and a properly performed semen analysis. Most general laboratories lack the expertise to perform a detailed sperm analysis and it is recommended that the test is performed in a lab where the testing confirms to the WHO 2010 criteria.

Semen analysis

A sample is collected by masturbation after abstaining from ejaculation for at least 48 hours, but not longer than five days. The complete ejaculate should be collected in a sterile container provided by the clinic or laboratory and should be examined within one hour of collection.

Semen quality is known to vary widely for a variety of reasons. It is therefore important to repeat a test if the first report is abnormal. Numerous factors can affect the results of semen analysis quite dramatically.

Further evaluation

If the semen analysis is abnormal, your doctor would need to examine you and perform an endocrinological evaluation (checking your hormones). Sometimes additional semen tests are needed. An ultrasound scan of the scrotum and evaluation of the blood flow by Doppler scan is occasionally needed. Genetic testing is needed if the sperm count is very poor or if there are no sperms seen in the semen sample

What can I do to improve my sperm quality?

Obesity has been clearly linked to impaired sperm production. Overweight men interested in optimizing fertility should attempt to attain an ideal body weight. Antioxidants have been found to result in a slight increase in both sperm count and motility. Fruits and vegetables also provide a natural source of antioxidants and should be part of a balanced and healthy diet. Smoking is associated with reduced sperm quality. Men who are trying to conceive should consider stopping smoking immediately. Also, recreational drugs, including anabolic steroids and marijuana, and excessive alcohol use are associated with impaired sperm function. They should not be used.

Some studies suggest that wearing boxer underwear, avoiding situations that raise scrotal temperature (like hot tubs or using laptops on your lap) might improve sperm quantity and quality. Further studies to confirm this are needed.

Some medications, along with chronic medical conditions and high fevers, may impair the body’s ability to make sperm.

Does infertility affect me and my relationship?

Fertility clinics tend to be focused on the treatment and as the vast majority of treatment is centred on women, it is easy for men to feel ignored, marginalised or as if they have no role to play other than to provide the sample when necessary. Many men find visiting the fertility unit uncomfortable and only attend when necessary. It may, of course, not be possible for both partners to attend all appointments but your partner and your relationship will benefit from your occasional presence and your support. The treatment is for both of you.

Men and women often have very different ways of dealing with problems and it can be very difficult to understand and accept this difference when you are going through this together. Women often say that their husbands won’t talk about their feelings and this is sometimes interpreted as not caring. It may be that your wife needs to talk about how she feels, either with you or with somebody else, more often than you. You and your wife will benefit from understanding and accepting each other’s different ways of coping.

Fertility treatment and the associated stress can sometimes have a very negative effect on your sexual life. What was once a pleasure is now a just a way to achieve a pregnancy. This can cause problems in your relationship and sometimes temporarily preventing you from being able to have sex altogether.


Tubes and Infertility

What are tubes and what is its role in achieving a pregnancy?

The Fallopian tubes are ‘pipe like’ structures on either side of the uterus which connect the inside of the uterus to the surface of the ovaries. Eggs released from the ovary are travel into the tubes at the time of ovulation. When a woman has sexual intercourse, the sperms travel from the vagina to the uterus and then to the tubes. If this happens close to the time of ovulation, one of the many sperms can ‘fertilise’ the egg leading to a pregnancy. This pregnancy then travels to the uterus and gets attached to the wall of the uterus and grows there.

Tubes and infertility

Since the tubes have a vital role in conception, damage to the tubes or a block in the tubes can cause infertility. Tubal damage can cause the pregnancy from moving normally to the uterus and to abnormally grow inside the tube – this is called an ‘ectopic pregnancy’.

What causes damage to the tubes?

The most common cause for tubal damage is infection. Tubal damage can be caused by sexually transmitted infections like Chlamydia and Gonorrhoea. Infections like tuberculosis can cause severe damage to the tubes. Appendicitis or infection from other pelvic organs can also cause tubal damage.
Using a surgical technique to ‘cut and separate the tubes’ is a method of permanent contraception (sterilisation). This needs to be reversed if a woman desires to conceive.
Scarring of the tubes can happen due to endometriosis, a previous tubal pregnancy and surgery to the tubes.
A rare condition called ‘salpingitis isthmica nodosa’ can cause blockage of the tube and prevent its normal functioning.

How is tubal damage diagnosed?

Most doctors rely on three tests to assess the functioning of the tubes: a hysterosapingogram (HSG), a hysterosalpingo contrast sonography (HyCoSy) and a diagnostic laparoscopy.
A hysterosalpingogram is an x-ray study in which a liquid, dye-like solution is injected through the cervix to assess the inside shape of the uterus and fallopian tubes. This procedure is performed before ovulation to avoid x-ray exposure to a fertilized egg. An HSG is performed while the patient is awake and causes moderate cramping. Using the HSG, your doctor may be able to tell whether the tubes are open or damaged, and whether the uterine cavity is normal.
A hystero contrast salpingography is similar to a HSG, but ultrasound is used instead of x-ray to assess the tubes.
Diagnostic laparoscopy is considered the ‘gold standard test’ as it can determine the patency and the outer condition of the tubes as well as the cause of tubal damage. This procedure is performed under general anaesthesia. The doctor inserts a laparoscope – which is a long, thin, telescope through an incision in the navel (belly button) into the abdominal cavity. Other small incisions in the abdomen may be made to insert various instruments to aid visualization of the fallopian tubes, ovaries, and other pelvic contents.
Laparoscopy is usually combined with hysteroscopy – a procedure where a very thin telescope like instrument is put through the cervix into the cavity of the uterus to assess it.
A dye is flushed into the uterus up through the tubes to determine if they are open. A problem which is diagnosed during laparoscopy is usually treated at the same sitting, which is a major advantage compared to the other tests.

How is tubal factor infertility treated?

Damage to the tubes can sometimes be corrected by surgery. This is not always possible and depends on the cause of the damage and the extent to which the damage has occurred.
A block to the tube at the point of attachment to the uterus can be corrected by a procedure called as trans-cervical cannulation, which is done at the time of a hysterolaparoscopy.
If the tubes are damaged because of a sterilisation operation, they can be ‘re-connected’ by a surgery called as ‘microtubal re-anastomosis’. If there are adhesions to the tube or in certain other cases of tubal damage, microsurgical procedures can be used to correct this.
Most of these surgeries were historically performed by an open surgery, but are now performed laparoscopically – giving both good success rates and early recovery
.

IVF for tubal factor infertility

In many cases, damage to the tubes cannot be treated by medicines or by surgery because of the extensive nature or severity of the disease. In such situations, the best option is IVF – where medications are given to stimulate egg growth, the eggs are collected under anaesthesia and fertilised with the man’s sperms. The resulting embryos are then put back in the uterus.