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Infertility an overview

INTRODUCTION

If you and your partner have been trying to have a baby for a year or more, you’re not alone. In fact. one out of seven couples will have trouble conceiving sometime during their reproductive years. During this time, you may experience frustration, jealousy, guilt, and anger. However, once you begin to explore your medical options, you’ll find that recent breakthroughs in medication, microsurgery, and in vitro fertilization techniques offer more hope for a successful pregnancy than ever before. In most cases today, experts can identify the male and female factors that reduce fertility. Pregnancy is now possible for more than half the couples pursuing treatment.

THE INITIAL VISIT

You may choose to be initially evaluated by a general obstetrician/gynecologist (ob/gyn), or you can go directly to an infertility specialist. While some infertility specialists are general gynecologists with a special interest in the treatment of infertility, other infertility specialists are reproductive endocrinologists.

Once you’ve decided upon a qualified physician, you will undergo a series of tests requiring a significant investment of time, money, and physical and emotional energy Before these tests are performed, your physician will ask questions and review any records that you and your partner may have from a previous infertility evaluation.

Insuring that your physician has access to previous medical records is critical to minimize wasted time and money for repeated diagnostic evaluation and therapy.Both of you should attend the first meeting together since infertility is a shared experience and is best dealt with as a couple. During this visit, you’ll begin to understand the degree of commitment and cooperation that an infertility investigation requires.

Causes of infertility are due to both male and female factors. In a typical interview the physician asks the woman if she has irregular periods, severe menstrual cramps, pelvic pain, abnormal vaginal bleeding or discharge, a history of genital infection, or medical illnesses. Also, expect questions concerning prior conceptions, prior miscarriages, pregnancies, operations, and methods to contraception. The man will be asked questions concerning genital injury operations, infection, drug and/or medication, usage, history of prior paternity, and medical illnesses. Your physician will ask both of you how long you’ve been trying to conceive, how often you have sexual intercourse, if you use lubricants during intercourse, and if anyone in your family has birth defects. Since 25 percent of infertile couples have more than one factor causing infertility, it is very important to evaluate all factors that may affect both the male and female partners.

The complete sexual and reproductive histories of each partner, including any former relationships, must be considered. During the first visit, many infertility physicians discuss the emotional stress of infertility, a subject that is often difficult to share with family and friends. Physicians know that the procedures and intimate questions involved in an infertility workup can be difficult. You should always feel free to make your physician aware of your concerns and frustrations.

A complete physical examination that directs special attention to the reproductive organs usually follows the interview. Your physician will be especially alert to signs of hormone imbalance and may schedule blood tests to measure hormone levels depending on your individual case.

Some physicians begin testing during the first visit based on indications from the history and physical examination of each partner. For example, it there is sign of an infection that could impair a future pregnancy, you or your partner may be tested immediately. Other tests must be performed at specific times during the woman’s menstrual cycle.

FERTILITY FACTORS

The Male Factor

In approximately 40 percent of infertile couples, the male partner is either the sole or a contributing cause of infertility. Therefore, a semen analysis is very important. The man is usually asked to abstain from ejaculating for 3 to 5 days. He will then collect a semen sample in a sterile container by masturbating in the close proximityof laboratory or at home. In some instances, a semen sample may be obtained during sexual intercourse using a special condom that does not contain substances which killthe spermatozoa. The semen specimen is examined under a microscope to determine the concentration, motility (movement), and morphology (appearance and shape) of thespermatozoa. In general, two or three semen analyses are recommended over a two to six-month period, since spermatozoa quality can vary over time. These and other tests help characterize sperm functions that are necessary for successful fertilization.

Frequently, a man will need to consult a urologist or another physician who specializes in male infertility. Treatment for male factor infertility may include antibiotic therapy for infection, surgical correction of varicocele (varicose veins in the scrotum) or obstruction of ducts, hormones to improve sperm production, and insemination of semen into the woman’s uterine cavity (intrauterine insemination).

In vitro fertilization (IVF) and other assisted reproductive technologies can also provide treatments for male factor infertility. Intracytoplasmic Sperm Injection is another option for treating severe male factor infertility.

Severe male factors may be unresponsive to treatment. If this occurs, your physician may discuss using sperm from an anonymous donor as another option in having a child.

The Tubal Factor

Because open, healthy fallopian tubes are necessary for conception, tests to determine tubal patency (openness) are important. Tubal and/or peritoneal factors account for about 35 percent of all infertility problems. If a hysterosalpingogram (HSG), an x-ray procedure, shows blocked tubes, scar tissue may be present. Your physician may perform a diagnostic laparoscopy to determine if adhesions have formed on the outer surface of the tubes and to what extent they interfere with tubal function. Since technical problems with either the HSG or laparoscopy can erroneously indicate tubal blockage, both tests may be necessary to adequately evaluate the fallopian tubes. Laparoscopy is an important part of a thorough infertility investigation and should not be unnecessarily delayed, especially in older patients. In younger patients, however, the physician may postpone laparoscopy if the HSG shows open tubes or if another problem is being treated. Even then, if no pregnancy occurs within six to 12 months of treatment, laparoscopy is almost
always suggested.

If the tubes are found to be blocked, scarred, or damaged, surgery can sometimes correct the problem. Although many tubal problems are correctable by surgery, women with severely damaged tubes are so unlikely to become pregnant that an operation is seldom attempted. If this is the case, in vitro fertilization (IVF) offers the best hope for a successful pregnancy.

The Ovulation Factor

A woman’s menstrual pattern may reveal some important clues about ovulation. Irregular or abnormal ovulation accounts for approximately 25 percent of all infertility cases. Charting the basal body temperature (BBT) is a simple, inexpensive way to see if a woman ovulates. A completed BBT chart will usually reflect the secretion of progesterone, a hormone that the ovaries produce after ovulation.

During the 12 to 16 days before the onset of menstruation, progesterone transforms the uterine lining into a receptive environment for implantation and nurturing of the fertilized egg.

To complete a BBT chart, a woman must take her temperature orally each morning the moment she awakens for at least one month and record the temperature daily under the appropriate date. Normally, the release of progesterone due to ovulation causes a midcycle temperature rise of 0.5 to 1.0 degrees Fahrenheit indicating that ovulation has occurred. If ovulation does not occur usually the temperature remains relatively unchanged. The BBT chart does not directly indicate ovulation or progesterone production. Many factors unrelated to the reproductive cycle, such as a cold or fatigue, can affect the BBT. At best, the BBT chart helps determine when and if ovulation occurs, but only after ovulation has taken place.

Your physician may recommend an over-the-counter ovulation prediction kit that is designed to detect the luteinizing hormone (LH) surge in the urine and to help predict the time of ovulation. The LH surge stimulates the ovaries to release eggs (oocytes) and produce progesterone.

Your physician may also perform a pelvic ultrasound examination to evaluate ovulation. This examination may indicate whether the ovaries are producing .follicles containing the immature eggs (oocytes). These follicles are fluid filled sacs (cysts) located just beneath the ovary’s surface. Ultrasound may also help to document the follicle’s collapse, implying release of the egg.

The results of BBT charting and ovulation prediction kits may suggest problems such as anovulation (lack of ovulation) or inadequate progesterone production which prevents the fertilized egg from successfully implanting in the uterine lining.

The BBT chart and ovulation detection kits are also helpful in scheduling tests that must be performed at specific points in the menstrual cycle.

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Fig 1:An endometrial biopsy in which a sample of endometrium is obtained.

Another procedure, the endometrial biopsy, also helps to evaluate ovulation. This procedure is performed in the physician’s office and takes approximately ten minutes. Just before menstruation begins, a small piece of tissue is removed from the endometrium, which is the inner lining of the uterus (Figure 1). This test may produce some discomfort and your physician may prescribe medication for pain relief prior to the procedure. Frequently, a pregnancy test is performed prior to the biopsy to make sure that the woman is not pregnant. The removed tissue is specially prepared by a pathologist and examined under a microscope to determine if it has responded adequately to progesterone production. The endometrial biopsy is usually obtained one to three days before menstruation is expected, typically day 26 of a 28-day cycle, which is when progesterone- induced changes in the endometrium are at their maximum. The endometrial biopsy can also be scheduled 12 to 13 days after the LH surge. Your physician must know the ovulation date or the starting date of the woman’s next period to interpret the biopsy. The tissue’s appearance under the microscope may reflect an inadequate progesterone effect on the uterine lining, called luteal phase defect. The treatment may consist of administering progesterone or ovulation drugs.
The ovaries begin producing large amounts of progesterone after ovulation. In a normal cycle, the progesterone level peaks about seven days after ovulation. Your physician may wish to measure the woman’s serum progesterone level at this time by drawing one or several blood samples. Generally, blood progesterone is tested on day 19 to day 23 of a 28-day menstrual cycle. An adequately elevated progesterone level helps to confirm ovulation.

If a woman is not ovulating, she may be prescribed medication to stimulate ovulation. Up to 80 percent of women taking ovulation drugs begin to ovulate regularly, and if no other factors need treatment, over half may become pregnant within the first six induced ovulations. More potent fertility drugs (given by injection) may be prescribed if oral therapy fails. In addition, your physician may want to order special tests to determine why the woman is not ovulating. The medical history and physical exam will help determine which tests are appropriate.

The Cervical Factor

Conditions within the cervix can contribute to infertility, but they are rarely the sole cause. In order to determine if there is a problem with the cervix, your physician may recommend a postcoital test (PCT). This test evaluates cervical mucus, sperm, and the interaction between the two. It is performed prior to ovulation and as close to the day of ovulation as possible. Your doctor may use an ovulation (LH surge) detection kit to help determine the proper day for the PCT.

At midcycle, the cervical mucus should be clear, colorless, watery, abundant, and stretchable. When these conditions are present, sperm can more easily pass up into the uterus and fallopian tubes. You and you partner will be asked to have sexual intercourse on a particular day of the woman’s menstrual cycle, or the day of or after the LH surge in her urine. Prior to visiting the physician’s office the woman may shower, but not take a bath, douche, or use any vaginal medications, sprays, powders, or creams after intercourse. About two to 18 hours after intercourse, a sample of the woman’s cervical mucus is taken during a routine pelvic exam and is immediately examined under the microscope. If the mucus is of good quality and adequate numbers of motile sperm have been deposited into the vagina, microscopic examination should reveal sperm swimming in a forward and progressive manner. This test is performed in the physician’s office, is painless, and takes just a few minutes.

If there is a below-average number of moving sperm, there could be problems with sperm production, delivery to the vagina, cervical mucus, or an immunological disorder. In the latter instance, proteins (antibodies) that kill or immobilize sperm are present in the cervical mucus, on the sperm surface, in the seminal fluid, or all three. Tests on cervical mucus, sperm, and blood from both partners may be necessary to detect these antibodies.

If mucus quality is poor or if the quantity is inadequate, the cervix may not be functioning properly. The most likely explanation is that the test was performed at the wrong time of the woman’s menstrual cycle. Another possible cause of inadequate cervical mucus production could relate to prior cervical surgery (e.g.cone biopsy).

Cervical problems are generally treated with antibiotics, hormones, or by intrauterine insemination. It is important for your physician to know it the woman has had prior biopsies, surgery, “freezing” and/or laser treatment of the cervix, abnormal pap smears, or if her mother took DES (diethylstilbestrol) while she was pregnant.

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Fig 2:Diagram of hysterosalpingogram, and actual X-ray (see inset)

A special x-ray called a hysterosalpingogram (HSG) can reveal defects of the inside of the uterus or fallopian tubes (Figure 2). An HSG is conducted after the woman’s menstrual period stops and before ovulation. A special media (dye) is injected through the cervix. It fills up the uterus and travels into the fallopian tubes to reveal uterine scar tissue, polyps (bunched-up pieces of the endometrial lining), fibroids or an abnormally shaped uterine cavity. These conditions, which are seen in about five percent of infertile women, can interfere with implantation of the early embryo or may increase the incidence of miscarriage. The HSG may also suggest blockage of the fallopian tubes. Surgery may be required to further evaluate and possibly correct uterine structural problems or blockage of the fallopian tubes.

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Fig3:Endometriosis

Hvsteroscopv may be recommended to further evaluate or treat abnormalities detected via HSG.

The Peritoneal Factor

The peritoneal factor concerns the conditions or abnormalities involving the peritoneal surfaces (peritoneum) of the pelvic organs or abdominal cavity, such as peritoneal adhesions or endometriosis. Laparoscopy, a surgical procedure that enables a physician to view the internal female organs, can reveal problems within the pelvic cavity such as scar tissue (adhesions) or endometriosis, which occurs when tissue that normally lines the uterus begins to grow outside the uterus (Figure 3). This tissue may grow on any structure within the pelvis and may form endometriomas in the ovaries. Endometriosis is found in about 35 percent of infertile women who have no other diagnosable infertility problem prior to laparoscopy.

Laparoscopy is usually performed under general anesthesia, often in the hospital’s same-day surgery unit. During the procedure, a narrow, lighted telescope-like instrument called a laparoscope is inserted through a small incision within or just below the navel. The physician then looks directly into the abdominal cavity and inspects the ovaries, tubes, uterus, and peritoneum (lining of the pelvis). A dye is usually injected through the cervix to determine if the passage to the uterus and tubes is open. One or more additional smaller cuts may also be made above the pubic area in order to better examine the pelvic organs and treat disease if it is found.

Laparoscopy is the simplest means of diagnosing peritoneal and tubal disorders. In addition, a variety of specialized surgical instruments, including lasers, may now be used laparoscopically to treat a wide variety of disease conditions, including endometriosis, adhesions, and ovarian cysts. In many cases, laparotomy, which involves an abdominal incision and up to a six-week recovery, is unnecessary because many problems can now be treated laparoscopically.

Unexplained Infertility and Uncommon Factors

In approximately 5 to 10 percent of couples seeking pregnancy, all of the above tests are normal, and in a much higher percentage of couples, only minor abnormalities are found. Many of these couples may choose to undergo more intensive testing for less common, subtle problems that cause infertility.

Fertility medications and/or intrauterine insemination have been used to empirically treat unexplained infertility with limited success. If no pregnancy occurs within three to six treatment cycles, a re-evaluation of factors may be necessary. Each couple has a unique set of circumstances, and the chances of treatment success vary widely. If treatment fails, couples still have the options of continuing the same therapy, re-evaluating the factors, and, in most cases, utilizing assisted reproductive technology (ART), donor insemination, or adoption.

Nationally, ART programs have an IVF success rate of about 15 to 20 percent (15 to 20 percent chance of a live infant born from a single cycle of IVF). The success of IVF depends on many factors, especially the female’s age and the reasons for her infertility. Couples who try IVF for three treatment cycles may have up to a 50 percent chance of becoming pregnant. Other new techniques of assisted reproduction include gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), donor embryo transfer, and micromanipulation. Cryopreservation or embryo freezing may be used with any of these techniques. Through the transfer of donor embryos, pregnancies can occur even in women who have no ovaries.

PSYCHOLOGICAL IMPLICATIONS

Infertility is a medical condition that has many emotional overtones for couples. You may experience feelings such as anger, sadness, guilt, and anxiety. These feelings can affect your self-esteem and your self-image. You may find it difficult to share your feelings with family and friends, which can lead to isolation. It is important to know that these feelings are normal and that you are not alone in what you are experiencing. While it is your physician’s responsibility to discuss realistically what your chances of pregnancy may be, only you and your partner can decide how far you want to go in your attempts to conceive.

SUMMARY

Sometimes the factors preventing pregnancy are easy to detect and resolve, but in many cases they are difficult to identify and treat. For such couples, extensive evaluation may be required before treatment can be recommended. Up-to-date management of infertility is not a guarantee of pregnancy, but a full evaluation can usually uncover one or more factors that reduce fertility. Your physician can then give you a reasonable idea of your chances of achieving pregnancy. The choice of which treatment to pursue, if any, is strictly a personal one. It may be necessary at times to temporarily cease therapy. In any case, the many options, such as assisted reproductive technologies and adoption, existing today allow most infertile couples to experience the joys of parenthood.