|FEMALE CAUSES||INCIDENCE||MALE CAUSES||INCIDENCE|
|Ovulation failure||30%||Sperm defect||80%|
|Tubal damage||15%||Coital factors||5% - 7%|
|Cervical mucus dysfunction||10%|
|Age > 40 years||15%|
Some couples may have more than one cause for their infertility. If you have already done investigations for your infertility elsewhere we DO NOT repeat these at our centre. We DO NOT do unnecessary investigations.
Women normally produce eggs quite regularly from age 20 to 35 if the menstrual cycle is regular. Even though the menstruation may start as early as 12 years, ovulation is often irregular till the age of 20. Similarly after the age of 35 years the ovulation becomes irregular and ultimately stops around the age of 50. Some women may stop producing eggs all together as early as 25 years of age. This is known as ovarian failure or premature menopause. To determine the ovarian function it is necessary to do ultrasound scan and hormone blood tests.
If the menstrual cycle is irregular then ovulation is irregular too. If this is the only cause of infertility, then ovulation induction is done either by tablets or by injections of hormones produced by the pituitary gland, FSH and LH mentioned earlier. Different methods of ovulation induction are explained later in this booklet. If the FSH is high which indicates ovarian failure then it is not possible to induce ovulation by using pituitary hormone FSH.
Fallopian tube dysfunction
Pelvic infection, treated or untreated may result in the distortion, partial or complete blockage of the fallopian tubes. Sometimes the pelvic infection may go unnoticed without any symptoms but still may cause tubal damage. Normally pelvic infection manifests with abdominal pain, foul vaginal discharge and fever. It may require hospitalization and treatment with antibiotics. Even with treatment, tubal damage and pelvic adhesions are common. In addition to tubal blockage the infection may also produce adhesions ( scar tissue ) between the tubes, ovaries, uterus and the bowel. This will prevent the egg from meeting the sperm thus causing infertility.
Another cause of pelvic infection is tuberculosis. Even if it was pulmonary or bone tuberculosis it can affect the reproductive organs. One of the recognisedcause of infertility is tubercular endometritis. This may cause intrauterine adhesions. This may require treatment before any fertility treatment is initiated.
Tubal dysfunction can also result from operations like appendisectomy, ovarian cyst removal, fibroid removal and caesarean section. Acute infection of the appendix can also affect the tubes due to its close proximity in the pelvis. Always ask your doctor whether surgery could be avoided as adhesions often reoccur even after surgery to remove the adhesions!
Previous operations of the cervix , cauterization or infection can obstruct the opening of the cervix. The cervix normally produces thick sticky mucus at the time of ovulation. This mucus helps the sperm to ascend up the cervical canal. The mucus may occasionally contain substances like anti sperm antibodies, which may reduce or stop the sperm motility or even kill the sperm.
The endometrium (inner lining of the uterus) is normally situated inside the uterus, lining the cavity of the uterus. It is this lining on which the fertilised egg has to implant to become a pregnancy. This lining is measured in thickness and quality by ultrasound scan during your treatment cycle.
In some women this lining may be present within the wall of the uterus (adenomyosis) or even outside the uterus, on the outer surface of the uterus, on the ovaries, the tube, bowel or the urinary bladder. This lining undergoes the same changes during the menstrual cycle whether it is in normal situation or elsewhere in the body. So it thickens under the influence of oestrogen hormone and softens under the influence of progesterone hormone. In the absence of a pregnancy the level of both oestrogen and progesterone hormone drop. This drop will cause crumbling of the endometrium which comes out as menstruation with blood if it is normally situated within the uterus. But if the endometrium is abnormally situated then the drop in the hormone levels will cause small amount of bleeding outside the uterine cavity that over a period of months and years will form cysts. The blood so collected will gradually change colour from red to dark brown over a period of time. These cysts are often called chocolate cysts because of the dark brown blood that they contain. Apart from distortion of the normal anatomy, endometriosis can immunologically reduce the chances of a pregnancy.
Polycystic ovarian syndrome
This is a very complex problem but we will try to explain to you as simply as possible.
In this condition the female will have very infrequent menstruation, abnormal growth of hair over the face and the body, infertility and excessive body weight. The menstrual cycle that has been regular may become irregular from 30 days to 90 days or even longer. This is because of the absence of regular ovulation every month.
Because of the abnormal utilization of the hormones in the body and slightly increased production of abnormal hormones like testosterone, excessive growth of hair on the face, chest, arms and legs can occur. Sometimes the hair growth is so bad as to need shaving, electrolysis, depilatory agents or laser. There is specific hormone treatment for the hair growth but unfortunately this cannot be given while having infertility treatment.
For excessive body weight the only option is diet, exercise and Metformin. It may be necessary to take hormones every month to regulate the periods even if you do not want to get pregnant. These women do not get pregnant because of anovulation ( no production of eggs ). This can happen even after producing one or two children. Abnormal hormone production and abnormal hormone utilization in the body will also cause excessive body weight in comparison to height thus increasing the body mass index ( BMI ). BMI over 30 is considered unfavourable for pregnancy. In PCOS there is also abnormally increased production of LH hormone from the pituitary gland. On ultrasound scan the ovaries show slight enlargement and small cysts underneath the surface of the ovary. These cysts are usually 2-3mm in diameter. Hence the name polycystic ovarian syndrome.
Apart from the ovulation problems there is also disturbed carbohydrate and cholesterol metabolism in polycystic ovarian syndrome patients. So has to look at long term health problems in such women. You can seek advice on these aspects of health problems during your consultation at the Centre.
Some women may have pain during intercourse because of infection, endometriosis, adhesions, bowel inflammation or bladder infection. So they do not have regular intercourse or not at all. Some young girls may be scared to have intercourse right from the beginning of their marriage. It is only the sperm by its active motility pass through the cervical mucus into the uterine cavity and not the whole semen that is ejaculated. There may be difficulty in intercourse because of congenital abnormality, erection or ejaculatory problem in the male. There may be other causes like emotional and / or psychological factors. These require careful evaluation and treatment is often difficult.
Woman's age is a very important factor in fertility. Most pregnancies occur between the ages of 25 and 35. After 35 years of age the incidence of pregnancy gradually decreases but after the age of 38 the decrease is more dramatic. At the age of 40 and over the pregnancy rates fall below 10% when compared to 35-45% at the age of 25 after infertility treatment. The reason for this poor outcome is the fact that the ovaries are gradually depleted of follicles and the ovaries become resistant to the stimulation from the FSH hormone. So when the ovarian stimulation is given in the treatment cycle the ovaries respond very poorly and produce less number of eggs than required. Since the ovarian follicles were present since the birth, the eggs from these follicles also age with the woman's age. Thus the eggs that are produced by the woman age 42 are 42 years old and the quality of these eggs is often very poor. They are often have abnormal chromosomes hence the pregnancy rates and miscarriage rates are extremely high.
The poor egg quality, the poor fertilization rate, poor embryo quality and poor implantation rates all contribute to the poor treatment success in older women. You must also remember that the early miscarriage rate at age 40 is around 50%. Also the risk of babies born with chromosomal abnormalities is 1:150 to 1:50. This will be discussed with you during your consultation.
A hormone blood test on day 2 or day 3 of a natural menstrual cycle may often predict the ovarian response to stimulation. This does not preclude us from treating older women particularly if she is trying for the first pregnancy. It is strongly advised that you should seek help in special infertility centre instead of spending time with inefficient treatments and waste your valuable time. We urge doctors both general practitioners and OB GYN specialists to refer the cases to special infertility centres as early as possible.
The sperm is produced in the testicles within small tubes called seminiferous tubules. These sperm then pass through coiled channels called epididymis where the sperm mature and gain some motility. Then they pass through the thick cord like vas deferens into the abdomen to be stored in a sac called seminal vesicle. Here the sperm mature further and gain more motility. The energy giving fructose sugar is added to the semen here.
At the time of intercourse the sperm from the seminal vesicle along with the secretions from the prostate gland and urethral gland are ejaculated as semen. The whole process of sperm production from the testis to ejaculation takes 70-90 days.
There could be defective, reduced or complete absence of production of sperm in the testes or blockage of the pathway or both which may affect fertility. To identify the problem it is necessary to perform a semen test in our laboratory where our reproductive scientist will carefully evaluate the sperm so that we can make an informed decision as to what is the best treatment for you. We do not accept the results of semen tests done elsewhere.
For the best assessment of the semen the husband should not have intercourse for three to four days before the semen test. The normal semen volume varies between 2-6millilitre. The sperm count varies between 20-200 million per millilitre. The motility varies between 20-50%. It also matters how the sperm move, whether they move forwards (forward progression) or move around in circles. The normality (morphology) is also important for fertility. The sperm abnormalities are mainly divided into head abnormality and tail abnormality. The normal morphology is 30-40%.
We also process the semen to assess the harvest of good sperms from the semen specimen. This process is called "swim-up". In addition the sperm survival over 6-24 hours is often performed. After the semen test, we will discuss the result and advice you the most appropriate treatment. Azoospermia( total absence of sperm in the ejaculate) could be due to obstruction in the passage of the sperm from the testes to the urethra OR could be complete absence of sperm production in the testes ((non obstructive - maturation arrest). Even in such cases there may be small areas in the testes which could be producing sperms. This can be detected by surgical exploration of the testes (TESA)
As the word implies, about 25% of the couples attending the infertility clinic have no reason why a pregnancy has not occurred in spite of extensive investigations. The wife will have regular ovulation resulting in regular menstrual cycle; the fallopian tubes have been proven to be patent either by hysterosalpingography or laparoscopy and having twice or thrice a week intercourse. The husband's semen analysis would have shown good sperm count and motility. Even the sperm antibody test would have been negative. In the present state of our knowledge and the scope of the investigations, these couple are considered to be having unexplained infertility. But these cases have a definite problem of fertilizing the eggs with husband's sperm. This can only be detected during IVF treatment. Such cases are advised to have ICSI.