Infertility: Brief introduction

Infertility occurs when a couple is unable to conceive after normal, unprotected sex.

One partner may not be able to contribute to the birth, or a woman may not be able to carry a pregnancy to full term. It’s also described as not conceiving without using birth control after 12 months of regular sexual intercourse.

In the United States, it is estimated that about 10 percent of women aged 15 to 44 have trouble in conceiving or staying pregnant. Eight to 12 percent of people worldwide encounter issues with fertility. It is thought that between 45 and 50 percent of cases stem from factors that affect the man.

Treatment is often available.

Causes in men

The following are common causes of infertility in men.

Semen and sperm

Semen is the milky fluid, produced during orgasm by a man’s penis. Semen is composed of both fluid and sperm. The fluid originates from the prostate gland, the seminal vesicle and other glands of women.

The semen resides in the testicles.

When a man ejaculates and releases semen via the penis, the seminal fluid, or semen, will help carry the sperm towards the egg.

The following issues may be:

• Low sperm count: The man ejaculates a low number of sperm. A sperm count of under 15 million is considered low. Around one third of couples have difficulty conceiving due to a low sperm count.
• Low sperm mobility (motility): The sperm cannot “swim” as well as they should to reach the egg.
• Abnormal sperm: The sperm may have an unusual shape, making it harder to move and fertilize an egg.

If the sperm is not in the right shape, or they can not travel quickly and accurately towards the egg, it can be difficult to conceive. It is assumed that up to 2 percent of men have suboptimal sperm.

Abnormal semen may not be able to carry the sperm effectively.

This can result from:

• A medical condition: This could be a testicular infection, cancer, or surgery.
• Overheated testicles: Causes include an undescended testicle, a varicocele, or varicose vein in the scrotum, the use of saunas or hot tubs, wearing tight clothes, and working in hot environments.
• Ejaculation disorders: If the ejaculatory ducts are blocked, semen may be ejaculated into the bladder
• Hormonal imbalance: Hypogonadism, for example, can lead to a testosterone deficiency.

Other causes may include:

• Genetic factors: A man should have an X and Y chromosome. If he has two X chromosomes and one Y chromosome, as in Klinefelter’s syndrome, the testicles will develop abnormally and there will be low testosterone and a low sperm count or no sperm.
• Mumps: If this occurs after puberty, inflammation of the testicles may affect sperm production.
• Hypospadias: The urethral opening is under the penis, instead of its tip. This abnormality is usually surgically corrected in infancy. If the correction is not done, it may be harder for the sperm to get to the female’s cervix. Hypospadias affects about 1 in every 500 newborn boys.
• Cystic fibrosis: This is a chronic disease that results in the creation of a sticky mucus. This mucus mainly affects the lungs, but males may also have a missing or obstructed vas deferens. The vas deferens carries sperm from the epididymis to the ejaculatory duct and the urethra.
• Radiation therapy: This can impair sperm production. The severity usually depends on how near to the testicles the radiation was aimed.
• Some diseases: Conditions that are sometimes linked to lower fertility in males are anemia, Cushing’s syndrome, diabetes, and thyroid disease.

Some medications increase the risk of fertility problems in men.

• Sulfasalazine: This anti-inflammatory drug can significantly lower a man’s sperm count. It is often prescribed for Crohn’s disease or rheumatoid arthritis. Sperm count often returns to normal after stopping the medication.
• Anabolic steroids: Popular with bodybuilders and athletes, long-term use can seriously reduce sperm count and mobility.
• Chemotherapy: Some types may significantly reduce sperm count.
• Illegal drugs: Consumption of marijuana and cocaine can lower the sperm count.
• Age: Male fertility starts to fall after 40 years.
• Exposure to chemicals: Pesticides, for example, may increase the risk.
• Excess alcohol consumption: This may lower male fertility. Moderate alcohol consumption has not been shown to lower fertility in most men, but it may affect those who already have a low sperm count.
• Overweight or obesity: This may reduce the chance of conceiving.
• Mental stress: Stress can be a factor, especially if it leads to reduced sexual activity.

Laboratory studies have indicated that long-term use of acetaminophen during pregnancy can affect male fertility by reducing the development of testosterone. Women are told to avoid using the medication for more than a day.

Causes in women

Infertility in women can also have a range of causes.

Risk factors

Risk factors that increase the risk include:

• Age: The ability to conceive starts to fall around the age of 32 years.
• Smoking: Smoking significantly increases the risk of infertility in both men and women, and it may undermine the effects of fertility treatment. Smoking during pregnancy increases the chance of pregnancy loss. Passive smoking has also been linked to lower fertility.
• Alcohol: Any amount of alcohol consumption can affect the chances of conceiving.
• Being obese or overweight: This can increase the risk of infertility in women as well as men.
• Eating disorders: If an eating disorder leads to serious weight loss, fertility problems may arise.
• Diet: A lack of folic acid, iron, zinc, and vitamin B-12 can affect fertility. Women who are at risk, including those on a vegan diet, should ask the doctor about supplements.
• Exercise: Both too much and too little exercise can lead to fertility problems.
• Sexually transmitted infections (STIs): Chlamydia can damage the fallopian tubes in a woman and cause inflammation in a man’s scrotum. Some other STIs may also cause infertility.
• Exposure to some chemicals: Some pesticides, herbicides, metals, such as lead, and solvents have been linked to fertility problems in both men and women. A mouse study has suggested that ingredients in some household detergents may reduce fertility.
• Mental stress: This may affect female ovulation and male sperm production and can lead to reduced sexual activity.

Medical conditions

Some medical conditions can affect fertility.

Ovulation disorders appear to be the most common cause of women’s infertility.

Ovulation is an egg which is published monthly. The eggs can never be released, or only released in some periods.

Ovulation disorders can be due to:

• Premature ovarian failure: The ovaries stop working before the age of 40 years.
• Polycystic ovary syndrome (PCOS): The ovaries function abnormally and ovulation may not occur.
• Hyperprolactinemia: If prolactin levels are high, and the woman is not pregnant or breastfeeding, it may affect ovulation and fertility.
• Poor egg quality: Eggs that are damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a woman is, the higher the risk.
• Thyroid problems: An overactive or underactive thyroid gland can lead to a hormonal imbalance.
• Chronic conditions: These include AIDS or cancer.

Problems with both the uterus or fallopian tubes that prevent the egg from traveling to the uterus or womb from the ovary.

If the egg doesn’t travel, natural conceivability can be harder.

Causes include:

• Surgery: Pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the uterus.
• Submucosal fibroids: Benign or non-cancerous tumors occur in the muscular wall of the uterus. They can interfere with implantation or block the fallopian tube, preventing sperm from fertilizing the egg. Large submucosal uterine fibroids may make the uterus’ cavity bigger, increasing the distance the sperm has to travel.
• Endometriosis: Cells that normally occur within the lining of the uterus start growing elsewhere in the body.
• Previous sterilization treatment: In women who have chosen to have their fallopian tubes blocked, the process can be reversed, but the chances of becoming fertile again are not high.

Medications, treatments, and drugs

Some drugs can affect fertility in a woman.

• Non-steroidal anti-inflammatory drugs (NSAIDs): Long-term use of aspirin or ibuprofen may make it harder to conceive.
• Chemotherapy: Some chemotherapy drugs can result in ovarian failure. In some cases, this may be permanent.
• Radiation therapy: If this is aimed near the reproductive organs, it can increase the risk of fertility problems.
• Illegal drugs: Some women who use marijuana or cocaine may have fertility problems.

Cholesterol

One study has found that high cholesterol levels may have an impact on fertility in women.

Treatment

Treatment may depend on multiple factors, including the age of the person who wants to conceive, how long the infertility lasted, personal interests and overall health status.

Frequency of intercourse

The couple may be recommended to have more regular sexual intercourse at ovulation time. Sperm can live up to 5 days inside the female while an egg can be fertilized up to 1 day after ovulation. In principle, on any of those 6 days that occur before and after ovulation, it is possible to conceive.

A study has shown, however, that the 3 days most likely to offer a fertile window are the 2 days before ovulation plus the 1 day ovulation.

Some say that to increase the supply of sperm, the amount of times a couple has intercourse should be decreased but this is unlikely to make a difference.

Fertility treatments for men

Treatment will depend on the underlying cause of the infertility.

• Erectile dysfunction or premature ejaculation: Medication, behavioral approaches, or both may help improve fertility.
• Varicocele: Surgically removing a varicose vein in the scrotum may help.
• Blockage of the ejaculatory duct: Sperm can be extracted directly from the testicles and injected into an egg in the laboratory.
• Retrograde ejaculation: Sperm can be taken directly from the bladder and injected into an egg in the laboratory.
• Surgery for epididymal blockage: A blocked epididymis can be surgically repaired. The epididymis is a coil-like structure in the testicles which helps store and transport sperm. If the epididymis is blocked, sperm may not be ejaculated properly.

Fertility treatments for women

Fertility drugs might be prescribed to regulate or induce ovulation.

They include:

• Clomifene (Clomid, Serophene): This encourages ovulation in those who ovulate either irregularly or not at all, because of PCOS or another disorder. It makes the pituitary gland release more follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
• Metformin (Glucophage): If Clomifene is not effective, metformin may help women with PCOS, especially when linked to insulin resistance.
• Human menopausal gonadotropin, or hMG (Repronex): This contains both FSH and LH. Patients who do not ovulate because of a fault in the pituitary gland may receive this drug as an injection.
• Follicle-stimulating hormone (Gonal-F, Bravelle): This hormone is produced by the pituitary gland that controls estrogen production by the ovaries. It stimulates the ovaries to mature egg follicles.
• Human chorionic gonadotropin (Ovidrel, Pregnyl): Used together with clomiphene, hMG, and FSH, this can stimulate the follicle to ovulate.
• Gonadotropin-releasing hormone (Gn-RH) analogs: These can help women who ovulate too early—before the lead follicle is mature—during hmG treatment. It delivers a constant supply of Gn-RH to the pituitary gland, which alters the production of hormone, allowing the doctor to induce follicle growth with FSH.
• Bromocriptine (Parlodel): This drug inhibits prolactin production. Prolactin stimulates milk production during breastfeeding. Outside pregnancy and lactation, women with high levels of prolactin may have irregular ovulation cycles and fertility problems.

Reducing the risk of multiple pregnancies

Injectable fertility medications may sometimes lead to multiple births, e.g. twins or triplets. With an oral fertility drug the risk of a multiple birth is lower.

During treatment and pregnancy careful monitoring may help to reduce the risk of complications. The through the fetuses, the higher the risk of premature labour.

When a woman requires an HCG injection to cause ovulation, and ultrasound scans indicate that too many follicles have formed, the HCG injection can be withheld. Couples may agree to go ahead, however great their urge to become pregnant may be.

If too many embryos develop, we can remove one or more of them. Couples ought to look at the legal and emotional aspects of this procedure.

Surgical procedures for women

If the Fallopian tubes are blocked or scarred, surgical repair can facilitate the passage of eggs.

Endometriosis may be treated by surgery with a laparoscopy. A small incision is made in the abdomen, and a thin, flexible microscope is inserted into it, with a light at the end, called a laparoscope. The surgeon will remove implants and cicatric tissue, which can minimize discomfort and improve fertility.

Assisted conception

The following methods for assisted reproduction are currently available.

Intrauterine insemination (IUI): a fine catheter is inserted into the uterus through the cervix at the time of ovulation, to place a sperm sample directly into the uterus. The sperm is washed in a fluid, and choosing the best specimens.

A low dose of ovary stimulating hormones can be given to the woman.

IUI is most commonly done when the man has low sperm counts, decreased sperm motility, or if the cause of infertility is not identifiable. When a man has serious erectile dysfunction, it can also improve.

In-vitro fertilization (IVF): Sperm is placed in a petri dish with unfertilized eggs, where it may be fertilized. Then, the embryo is inserted in the uterus to start a pregnancy. The embryo is periodically frozen for future use.

Intracytoplasmic sperm injection (ICSI): In an IVF procedure, a single sperm is inserted into an egg to achieve fertilization. The probability of fertilization for people with low sperm concentrations is increasing significantly.

Sperm or egg donation: You will obtain sperm or eggs from a donor if appropriate. Donor egg fertility therapy is normally performed using IVF.

Assisted hatching: The embryologist opens a small hole inside the embryo’s outer membrane, known as the pellucid region. The opening enhances the embryo’s ability to implant within the uterine lining. It increases the odds of the embryo implanting on, or sticking to, the uterine wall.

It can be used if IVF has not been successful, if the rate of growth of the embryos has been low, and if the woman is older. For some women the membrane becomes harder, and particularly with age. That can make the implanting of the embryo difficult.

To induce ejaculation, electric or vibratory stimulation: Ejaculation is accomplished with electric or vibratory stimulation. For example, this can support a man who is unable to ejaculate normally due to a spinal cord injury.

Surgical sperm aspiration: part of the male reproductive tract, such as vas deferens, testicles, or epidididymis, extracts the sperm.

Types

Infertility can be primary or secondary.

Primary infertility is when a person has not conceived after at least 12 months of attempting without using birth control Secondary infertility is when they have conceived previously but are no longer able to.

Diagnosis

Most people will visit a doctor after 12 months of trying, if there is no pregnancy.

If the woman is over 35 years of age, the couple may want to see a doctor sooner as fertility tests can take time, and when a woman is in her 30s, female fertility begins to drop.

A doctor can offer advice and do some preliminary assessments. With such a couple, it is better to see the doctor together.

The doctor can ask about the sexual habits of the couple, and make recommendations about them. There are studies and examinations available but testing does not always show a specific source.

Infertility tests for men

The doctor will ask the man about his medical history, medications and sexual habits and will conduct a physical exam. The testicles will be tested for lumps or deformities, and it will investigate the shape and structure of the penis for abnormalities.

• Semen analysis: A sample may be taken to test for sperm concentration, motility, color, quality, any infections, and whether any blood is present. Sperm counts can fluctuate, so that several samples may be necessary.
• Blood test: The lab will test for levels of testosterone and other hormones.
• Ultrasound: This may reveal issues such as ejaculatory duct obstruction or retrograde ejaculation.
• Chlamydia test: Chlamydia can affect fertility, but antibiotics can treat it.

Infertility tests for women

A woman will undergo a general physical exam and the doctor will ask about her medical history, drugs, menstrual cycle and sexual habits.

She must also undergo a gynecological checkup and other tests:

• Blood test: This can assess hormone levels and whether a woman is ovulating.
• Hysterosalpingography: Fluid is injected into the woman’s uterus and X-rays are taken to determine whether the fluid travels properly out of the uterus and into the fallopian tubes. If a blockage is present, surgery may be necessary.
• Laparoscopy: A thin, flexible tube with a camera at the end is inserted into the abdomen and pelvis, allowing a doctor to look at the fallopian tubes, uterus, and ovaries. This can reveal signs of endometriosis, scarring, blockages, and some irregularities of the uterus and fallopian tubes.

Other tests include:

• ovarian reserve testing, to find out how effective the eggs are after ovulation
• genetic testing, to see if a genetic abnormality is interfering with fertility
• pelvic ultrasound, to produce an image of the uterus, fallopian tubes, and ovaries
• Chlamydia test, which may indicate the need for antibiotic treatment
• thyroid function test, as this may affect the hormonal balance

Complications

Infertility and its treatment can cause some complications. If, after several months or years of attempting, pregnancy does not occur, it may lead to stress and probably depression.

The treatment can also cause certain physical effects.

Ovarian hyperstimulation syndrome

The ovaries can swell, leak excess fluid into the body, and create too many follicles, the small fluid sacs in which an egg is produced.

The condition of ovarian hyperstimulation (OHSS) typically results from drugs to stimulate ovaries such as clomifene and gonadotrophins. This can grow after IVF, as well.

Symptoms include:

• bloating
• constipation
• dark urine
• diarrhea
• nausea
• abdominal pain
• vomiting

Generally they are mild, and simple to treat.

Rarely, a blood clot develop problems in an artery or vein, liver or kidney, and there may be respiratory distress. OHSS can be deadly, in extreme cases.

Ectopic pregnancy

This is when an implants a fertilized egg outside the womb, normally in a fallopian tube. If it remains in there, complications, such as fallopian tube rupture, may develop. Any hope of extending this pregnancy.

Immediate surgery is needed, and the tube on that side will sadly be lost. Potential pregnancy with the other ovary and tube is also likely.

The risk of an ectopic pregnancy is significantly higher for women undergoing fertility care. An ectopic pregnancy can be detected by an ultrasonic scan.

Coping mentally

It is difficult to say how long and how effective treatment can proceed. It can be difficult to cope and to persevere. Both partners may be affected by the emotional toll.

Many people feel that attending a support group helps because, in a similar situation, it provides the ability to speak to others.

Should excessive mental and emotional stress develop, telling a doctor is vital. Sometimes, they will suggest a counselor and those who can provide appropriate help. It can be helpful to get online support from organizations like Resolve.

Outlook

There are more options available for people suffering fertility issues and those wanting to have children at an older age than ever before.

The first baby was born on IVF in 1978. By 2014, after conceiving it via IVF, more than 5 million people were born.

As advanced technology becomes available, care for fertility is now accessible to more people and success rates and safety are continually increasing.

This can also be expensive to finance fertility care, but there are services that can assist with that.