Male Infertility

 

Gone are the days when the female partner was considered to be solely responsible for not being able to bear a baby. We now know that the male partner is responsible for almost 50% of all infertility cases. Problems in male range from erectile dysfunction, ejaculatory problems and problems in sperm count, motility and morphology. A minimum of 15 million/ml of sperm count is considered normal. Count less than 15million /ml is abnormal and is called oligospermia. Similarly  presence of a minimum of > 40 % motile sperm is considered normal. Motility less than normal is called asthenozoospermia. Morphology is the study of structural form of a sperm. A minimum of 4 % of sperm is required to be normal. Morphology less than 4 % is called Teratozoospermia. There are cases in whom the sperm count is very very  low and such cases are called Cryptozoospermia. Total absence of sperm is called azoospermia. There are two types of azoospermia, Obstructive  and Non- obstructive. In obstructive azoospermia there is normal production of sperms in the testicles , but there is a blockage in the tubes carrying the sperms from the testes to the male urethra. Such blockage may be at the level of epididymis or the the level of vas deferens. In some cases there is congenital absence of vas deferens. In Non- obstructive azoospermia the testicles are small and there is  scanty or no sperm production.

Female Infertility

 

ENDOMETRIOSIS

 

Endometriosisis a condition in which tissue similar to the lining inside the uterus (called “the endometrium”), is found outside the uterus, where it induces a chronic inflammatory reaction that may result in scar tissue.  It is primarily found on the pelvic peritoneum, on the ovaries, in the recto-vaginal septum, on the bladder, and bowel.  In very rare cases it has been found on the diaphragm and in the lungs .

 

 Endometriosis affects an estimated 1 in 10 women during their reproductive years (ie. usually between the ages of 15 to 49), which is approximately 176 million women in the world.However, endometriosis can start as early as a girl’s first period, and menopause may not resolve the symptoms of endometriosis – especially if the woman has scar tissue or adhesions from the disease and/or surgery.

 

The symptoms of endometriosis include painful periods, painful ovulation, pain during or after sexual intercourse, heavy bleeding, chronic pelvic pain, fatigue, and infertility, and can impact on general physical, mental, and social well being .A general lack of awareness by both women and health care providers, due to a “normalisation” of symptoms, results in a significant delay from when a woman first experiences symptoms until she eventually is diagnosed and treated .

 

There is no known cure and, although endometriosis can be treated effectively with drugs, most treatments are not suitable for long-term use due to side-effects . Surgery can be effective to remove endometriosis lesions and scar tissue, but success rates are dependent on the extent of disease and the surgeon’s skills.

 

Pregnancy may relieve symptoms but is not a cure for the disease. Hysterectomy, with surgical removal of all the disease at the same time, may relieve symptoms, but may not be a “definitive cure” either. Removal of the ovaries at the same time as a hysterectomy is performed increases the chances of pain relief but also results in an immediate menopause.

 

There is no known cause of endometriosis but it is highly likely that certain genes predispose women to develop the disease . Thus, women have a higher risk of developing endometriosis if their mother and/or sister(s) are also affected . It is possible that age when the menstrual period starts, other gynaecologic factors, and environmental exposures influence whether a woman is affected.

 

Infertility treatment in patients of endometriosis depends on the severity of the disease, duration of infertility and other co- existing problems like any tubal pathology or male factor for infertility. A definite diagnosis and surgical correction by laparoscopy is always the first line of treatment. Those having mild to moderate disease can be treated with ovulation induction and IUI. Those with moderate to severe disease can be taken up for IVF.

 

 

PCOD ( Polycystic ovarian disease)

 

With our fast changing lifestyle in the form of sedentary habits, lack of exercise, high calorie diet, stress etc , the incidence of obesity is on the rise in thr adolescent and reproductive age population of our country. This has resulted in  the rise of a new disorder called PCOD. Across the globe approximately 4-11 % of female population suffer from PCOD. Exact incidence in our country is not known, but it is fast growing in the urban population of our country, with the incidence as high as 15-20 % of women in the reproductive age group.

 

This is a disorder which basically effects the ovaries of a woman, the organ responsible for the production of eggs in females. In PCOD, there is a dysfunction of egg production by the ovaries, resulting in delayed menstrual cycles and failure of conception. The hormones production by the ovaries is also disordered. More of androgens(male hormones) are produced than normal, which causes acne, hirsuitism( increased hair growth) etc. Diagnosis of PCOD is made from the history of delayed periods, signs or blood report of increased androgens and ultrasonography of the ovaries which show multiple small sub- capsular follicles.

 

The effect of PCOD is not just confined to the reproductive function in women. It can cause a spectrum of problems ranging from obesity, diabetes, high cholesterol, heart disease and even endometrial carcinoma. Many patients have increased insulin levels, abnormal lipid profile, impaired glucose tolerance or even diabetes. There is a increased tendency of women with PCOD to have coronary artery disease due to dyslipidemia. Continued high levels of estrogen due to absence of ovulation, increases the chances of endometrial carcinoma. PCOD women are more prone to develop depression, anxiety, and eating disorders. Although most of the patients are obese, there is a group of lean patients also who suffer from PCOD.

 

The exact cause of the disease is not known, but there is basically a genetic predisposition in some women, which gets manifested due to life style changes.Loss of weight, regular exercise and low glycemic index diet can help overcome many of the symptoms of PCOD.

 

Treatment of PCOD depends on the woman’s stage of life and their chief complaint. For younger married women who desire birth control, oral contraceptive pills work well to regularize the menstrual cycles. Metformin is a very effective drug which helps normalize some degree of hormonal imbalance and also lose weight.Many women start menstruating regularly and ovulating with metformin treatment alone , especially obese women.For women who desire pregnancy, ovulation induction drugs like clomiphene citrate and gonadotropins can be used under strict medical supervision.Few patients who do not respond to drugs for ivulation induction, operative treatment like laparoscopic ovarian drilling may sometimes be needed. Some patients may also need controlled ovarian stimulation followed by IVF-ET.

Blocked Fallopian tubes:

 

Blocked fallopian tubes is one of the important causes of female infertility. Fallopian tubes transport the egg from the ovaries to the uterine cavity. It takes 4-6 days time for the egg to travel the distance of the fallopian tube. In the process of travel if a sperm is available the egg gets fertilized to form a zygote and then an embryo. Blockage of the tubes prevent the sperm and egg to meet.

There are many reasons for the tubes to get blocked. Infection being the most important cause. Tubes can get infected from previous abortions, pelvic surgeries, sexually transmitted infections, tuberculosis etc. Endometriosis may also cause tubal adhesions and blockage.

 

 

Advanced age group women

 

In recent times, the status of women has changed from a mere housewife to an educated, professional, bread earner and an important member of the society. But this change in status has compromised her on another very important aspect of her life i.e the ability to bear a child. Women delay marriage for her education, and after marriage delay pregnancy due to her professional demands. As a result almost 30- 40 % women visiting an infertility clinic are above 35 years age.

It is a known fact that the ability of a woman to become pregnant decreases with their increasing age. Women are born with a fixed number of eggs in their ovaries which decreases as she grows old. After  the age of 35, this fall in number of eggs becomes exponential and there is a rapid fall in fertility. Apart from the decrease in the number of eggs, the quality of the eggs also deteriorate .Advanced age leads to decreased libido and infrequent coitus.

Although many women above 35 years do conceive spontaneously, but majority of them have to undergo some form of evaluation and treatment. In recent times medical science has made significant progress as far as infertility management is concerned. Elderly women should consult a doctor and undergo evaluation and necessary treatment at the earliest. Patients can be counseled to increase chance of conception and also undergo various treatments to enhance fertility. Elderly patients who fail to conceive may under ART. Patients with very poor ovarian reserve or ovarian failure may undergo IVF with Donor Eggs.

In donor egg IVF, eggs are collected from the donor, fertilized with the sperms of the husband and embryo  transferred into the uterus of the patient. This treatment is very successful even in women who have undergone menopause.