Infertility

 

Causes of infertility

Fertility is a complicated thing. The complex and finely balanced process involved egg and sperm production and many factors plays role in fertilization to implantation.

Great research and studies have been achieved in infertility treatment, once the cause for infertility is identified, treatment aimed at correcting reversible etiologies and overcoming irreversible factors can be implemented with advances in assisted reproductive technology, and treatment for female infertility has made enormous progress. ART techniques combines use of fertility drugs, hormonal therapy, surgery, IUI, IVF/ICSI-ET, Egg donation, Embryo donation and Surrogacy

Causes for Male Infertility:

Male infertility accounts 35-40% of all fertility problems and it can be classified into four main types.

It is estimated that one in six couples face difficulties in conceiving. The chart below outlines the most common causes and typical treatments available.
Azoospermia : – Causes & possible solutions
Azoospermia – No sperm in the ejaculate

Retrograde ejaculation [during orgasm, sperm Enter the bladder & mix With urine ]

Causes
No production of sperm in the testes [because of trauma,mumps, Hypogonadism surgical removal, Chemo or Radiotherapy] of testis, undesanded testis.

sperm production is there, but cannot enter in ejaculated semen. [obstruction at various levels in the path way of genital tract ]

Obstructive Azoospermia

  • Epididymal block [infections]
  • Congenital absence of vas [Bridging tube between testis And penis]
  • Infection to vas or vasectomy
  • seminal vesicle or prostate pathology

Non obstructive Azoospermia

  • unknown cause
  • system appears normal but no sperm in ejaculate

Possible Solutions :-

  • ICSI For obstructive and non-obstructive Azoospermia(Normal spermatogenis, no sperm in the ejaculate)
  • Sperm donation
    • No sperm in the testis
    • can’t afford IVF-ICSI treatment.
Oligo Asthenozoosperima
[Abnormality in number, morphology and movement of sperm]

Causes :

  • Hormone deficiency
  • Hyper prolactanemia
  • Varicocele [abnormal swollen blood vessels around the testicles]
  • Infection
  • Use of certain drugs like antidepressants, anticancer and anti hypertensive
  • Use of steroids
  • Excess alcohol
  • Heavy smoking
  • Frequent hot baths or saunas
  • Antisperm antibodies
  • Testicular cancer
  • Life style variation [physical, mental stress & strain, pollution, unbalanced diet]
Happy Familiy
Possible solutions :

  • Fertility drugs to increase sperm production
  • Use of Antioxidants invitro or invivo
  • Change in life style
  • Balanced diet
  • IUI
  • IVF-ICSI
  • Use of donor sperms.

Impaired sperm fertilization capacity or sperm dysfunction :

  • Morphologically normal sperms, but fail to penetrate the oocyte[egg]

Causes :

  • Defective Acrosome
  • Abnormal lateral head movements of sperm
  • Inability of sperm to bind to the zona pellucida
  • Excess free oxygen radicals in the semen.

Possible solutions :

  • Treatment with antioxidant to reduce the level of free oxygen radicals either invivo or invitro
  • ICSI

Inability to ejaculate in the vagina :

Causes :

Penile problems

  • very small penis
  • obesity
  • premature ejaculation
  • impotency – psychological or pathological
  • hypo and epispadiasis

Possible solutions :

  • counseling in case of premature ejaculation
  • reduction of weight for obese
  • IUI , IVF or ICSI in case of epi or hypospadiasis
  • Supportive medicines to sustain erection

Immunological infertility :
Antisperm antibodies can be present in either or both the partners. It can be present in blood, cervical mucus, or ejaculate.

Causes :

  • Genital infection
  • Trauma to the testicles
  • Varicocele
  • Vasectomy
  • Reversal of vasectomy

Possible solutions :

  • Sperm washing and IUI / IVF/ICSI
  • Immuno suppressive drugs.

Coital failure :

Causes :

1.Lack of Libido

  • excess physical or mental strain
  • psychological
  • testosterone deficiency
  • High prolactin levels

Treatment

  • counseling
  • correction hormones, yoga, meditation, change of life style for stress

Physical problem :

  • spinal cord injury
  • prostatectomy
  • bladder neck surgery
  • multiple sclerosis
  • chronic illness
  • side effects of drugs
  • excess alcohol
  • premature or delayed ejaculation
  • failure of erection or anejaculation
  • congenital penile abnormalities
Mother & Baby

Treatment

  • psychosexual therapy
  • sex education
  • IUI/IVF
  • Surgical correction of congenital problem of penis

Unexplained Infertility :
None of the investigations are abnormal through investigations.
Possible solution :

  • IUI/IVF / ICSI

Varicocele, undescended testis, obstruction in sperm conduction pathway and some time for vasectomized male, recanalization can be done through surgical techniques
Causes For Female infertility :
1. Vaginitis : infections like candidial , fungal, mixed bacterial infections can change the PH alkaline to acidic and in case of Acidic PH sperm cannot survive.

Solution :Treatment of respective infections
2. Cervical mucous hostility :

  • The post coital test is used to check for the presence of “hostile” cervical mucus. It is performed up to 12 hours after intercourse. A small amount of mucus is taken and checked for amount of elasticity of the mucus and the number and quality of sperm present in the sample.
  • If mucus is not enough, too thick or sticky it won’t allow the sperm to move easily.

Cause : poor estrogen stimulation, cervical glands, or infection of cervical glands, H/o cervical surgery, presence of antisperm antibodies in the mucus.
Treatment

  • correction of infections
  • use of condom for 2-3 months to reduce antibody level
  • use of immunosuppresants to counter antibodies
  • IUI- IVF – ICSI

3. Ovulation problems :
a) Ovulation irregularity or anovulation :
This happens because of Hypothalomo pituitary ovarian axis dysfunction. Some times other hormones like thyroxin, prolactin insulin interfere this process.

Treatment : ovualiton inducing agents Ex : CC, tomoxifen, gonadotrophin injections, oral antidiabetics, correcting the prolactin and thyroxin levels.

b) Absent ovary :

  • by birth
  • surgical removal
  • premature ovarian failure
  • menopause

Possible solution  :ovum donation and IVF treatment
4. Uterine problems :

a)  Anatomically abnormal

  • different size and shape of uterus by birth ex: septate uterus, bicornuate uterus etc.

Solution : some times it contributes for infertility. Thus surgical correction has to be done.
b)  Uterine pathology

  • fibroids – surgical removal if necessary

Myomectomy [ Removal of Fibroids]

  •  Myomectomy is a surgical procedure that primarily addresses superficial tumors of the uterus or fibroids. For e.g. pedunculated tumors that have a stalk and are separate from the uterine muscle, and easily reachable tumors on the outer surface of the uterus.
  • In traditional myomectomy a bikini incision will be used, but for large tumors sub umbelical midline incision will be used to accommodate for the enlarged uterus.
  • Adenomiosys– suppression with pregesteron
  • Endometrial Polyps – surgical removal

Polypectomy [ Removal of poly P]

  • either by hysteroscpe or by simple D & C procedure poly p can be removed.
  • Infections- treatment of infections
  • Thin Endometrium [inner layer of uterine wall]
    • Infections
    • Repeated D&C


Possible solution

treatment of infections, hydrotubation with drugs, some times to separate the wall of uterus and allow growth of endometrium.
Copper T is inserted for 2 months.
Some times supplements of estrogen and progesterone
If there is thick endometrium i.e endometrial hyperplasia suppress the estrogen hormone oral pills for 3 monhts, or GnRHa Depo injection for 1-2 months, or D&C once.
5. Tubal problems :
Causes : infections

  • Ascending
  • Systemic

Ascending : through intercourse ex: Gonorrhea, Chlamydia etc, after D&C, Copper T, delivery or abortion either spontaneous or evacuation and curettage.

Systemic : Tuberculosis either directly to genital system or subclinical spread from other parts of the body.
Post infections : any infections damages the tubular structure specially inner layer of tubal wall epithelium. So that transport and nutrition of sperm is affected, and they can get killed due to presence of toxins.
6. Poor Egg quality

  • chromosomal abnormalities
  • exposure to toxins, chemicals, radiation etc

Possible solution : Egg donation

7. Polycystic ovarian syndrome :
Too many follicles, none reaches mature state. Here we find irregular menstrual cycle, hirsutism , presence of Acne, weight gain etc, anovulaiton

Possible solution :

  • ovulation induction drugs
  • Laparoscopic microcauterisation of ovarian capsule
  • Laser Assisted hatching at the time of IVF
8. Endometriosis :
Endometriosis is defined as presence of actopic endometriam other than natural place.

It occurs when tissue (which lines the uterus) is found outside the uterus – usually in the abdomen, on the ovaries, tubes, and the area between the vagina and rectum, the outer surface of the uterus and the lining of the pelvic cavity, utero-sacral legaments. Other sites for these endometrial growths may include the bladder, bowel, vagina, cervix, vulva and in abdominal surgical scars.


Causes of endometriosis :

  • The cause of endometriosis is unknown. The retrograde menstruation theory suggests that during menstruation some of the menstrual tissue backs up through the fallopian tubes, implants in the abdomen and grows.
  • Another theory suggests that endometrial tissue is distributed from the uterus to other parts of the body through the lymph system and through the blood system.
  • A genetic theory suggests that it may be carried in the genes in certain families.
  • One theory suggests that remnants of tissue form when the woman was an embryo may later develop into endometriosis.

Possible solution :

The goal of variety of treatments include relieving pain symptoms, shrinking or slowing endometrial growths, preserving or restoring fertility and preventing recurrence of the disease.

a. Drugs : [for Grade I and II Endometriosis ]Pain relievers may include aspirin, prostaglandin, inhibitors such as ibuprofen, naproxen sodium,

b.Hormonal Therapy : [for Grade I and II endometriosis] It aims to stop ovulation for as long as possible and may include oral contraceptives , progesterone drugs and GnRH agonist.

c. Surgery : [for Grade III and IV Endometriosis] This procedure can be either done with laparoscopy or with laprotomy. The procedure involves the endometriosis being cut away or burned, and the adhesions divided. Chocolate cysts are removed and their lining destroyed to prevent the cyst from reforming.

d. IUI / IVF/ICSI : women with minimal or mild endometriosis, who have healthy tubes are advised for artificial insemination. For severe to moderate endometriosis IVF / ICSI is an effective treatment.

9. Immunological Infertility :

Affects entry of sperms in the genital tract or into egg. Antibodies against sperm can be there at any level of genital tract. If it is in the tract sperm cannot reach the egg. If there is antibody over zona pellucida of egg – sperm cannot penetrate the egg.

Possible solution :

  • Immuno suppression/ IUI/IVF – if Antibody in the genital tract.
  • ICSI – antibody over zona pellucida.
  • Genital tract infection should be treated

10. Coital Failure :

Causes :

  • psychological fear
  • congenital abnormalities [ rigid/rough/ hymen, narrow entrance]
  • Vaginitis
  • Infections
  • Endometriosis

Possible solutions :

  • psychological counseling
  • surgical correction
  • use of lubricants , pain killers, tranquilizers
  • treatment of infection

11. Unexplained infertility :

Causes :
None after thorough investigations of both partners, however possible causes include

  • Defective fimbriae, unable to pick up the egg at ovulation
  • Sperm lacking the fertilizing capacity
  • Defective endometrium – lack of necessary cascade of chemicals like interferons, interlukins, TNF and growth factors etc.
  • Psychological

Possible solutions :

  • IUI/IVF /ICSI
  • If couple won’t get success through this treatment ovum, sperm or embryo donation are the options
  • [Third party reproduction ]- surrogacy