Couples around the world are facing the issue of infertility. A successful career is a priority amongst young couples. The choice to delay starting a family to focus on other aspects of life is one of the leading causes. Still, an unhealthy lifestyle is equally responsible for an increase in infertility.

In men, factors such as cigarette smoking, alcohol consumption, drug abuse, obesity, psychological stress and coffee consumption are linked to a decrease in sperm count and quality, leading to male infertility.

In women, the peak reproductive age is around the late teens and early twenties. After that, the fertility rate amongst females starts declining beyond 30, and after 45, conceiving’s naturally become extremely difficult. In addition, most women delay motherhood to progress ahead in their careers. These changes, along with other conditions, necessitate the need for artificial modes of reproduction.

Physiology of Pregnancy

A menstrual cycle is observed to begin on the first day of a period. On average, a regular cycle lasts 28 days, but some women can have cycles as short as 21 days or as long as 35 days. The monthly changes a woman’s body undergoes to get ready for a potential pregnancy is known as the menstrual cycle.

A successful pregnancy occurs when a sperm fertilizes an ovum in the fallopian tube, and the  embryo is implanted in the inner lining of the uterus(endometrium). Sperms are present in semen which is a male bodily fluid. The sperms travel in the female reproductive tract once the semen has been deposited in the female body. The sperms travel upwards to reach the fallopian tube.

Every month the female undergoes ovulation (release of an egg); this egg is present in the fallopian tube. Once the sperm encounters the egg, it undergoes physical and chemical changes to allow a single sperm to enter. Once successfully , the egg travels downwards towards the endometrium, where it implants itself. If successfully implanted, the embryo is carried to term in the uterus, where it derives nutrition from the endometrium to grow into a fully developed human baby.

What is Infertility?

Infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex. Pregnancy is a complex sequence of events which involves both male and female reproductive organs to function correctly. Thus there can be multiple causes of infertility.

Causes of Infertility

There can be multiple causes of infertility—congenital, infectious, chronic and lifestyle related, amongst others. However, they can broadly be divided into male and female causes. Here are a few common causes:

Causes of Infertility In Men

One of the most commonly overlooked causes of infertility is male infertility.

Semen and Sperm

A semen analysis is one of the tests that your doctor might order. A semen analysis, along with a complete physical assessment, is crucial for male infertility examination. This test assesses various features of semen and sperm like pH, total sperm count, morphology, progressive motility, total motility, sperm viscosity and others. For example, a decreased sperm count or reduced sperm motility are some abnormal findings in a semen analysis.

Testicles

Sperms are produced and stored in the testes. Multiple causes can affect testes like testicular cancer, testicular trauma, congenital testicular defects or undescended testes.

Problems with Ejaculation

Ejaculation is the ejection of semen from the body. Various problems are associated with ejaculation, such as premature ejaculation and retrograde ejaculation. If you are facing any of these issues, contact your doctor.

Certain Drugs

Certain drugs, like chemotherapy agents, antibiotics, steroids, etc., affect sperm count. Therefore, your doctor will require a thorough history to diagnose the cause of infertility.

Causes of Infertility in Females

Female infertility can be due to various reasons, but the most common causes of infertility are problems in ovulation. Here are a few other common causes of female infertility: 

Ovulation Disorders:

• PCOS, or Polycystic Ovary Syndrome, is the most common cause of infertility in women across the world. PCOS occurs to a hormonal imbalance seen in women who belong to the teenage or childbearing age group. It is thought to occur because of obesity and insulin resistance.
• Thyroid dysfunction and underperforming or overactive thyroid have been associated with disrupted ovulation leading to infertility.
• Premature ovarian failure means the failure of the ovaries to produce more eggs before the age of 40. Usually, the ovaries continue producing eggs till beyond forty.

Cervical Mucus Issues

For a smooth upward journey up the female reproductive tract, sperms require a smooth, watery medium to travel. During ovulation, cervical mucus becomes thinner to ensure smooth upward travel of sperms. Any deviation from this leads to sperm not reaching the egg and a failure to get pregnant.

PID

Pelvic inflammatory disease is an infection of the upper female genital tract. The fallopian tube, uterus and ovaries all can be affected by PID. The most common cause of PID are sexually transmitted diseases (STI), Gonorrhoea and Chlamydia pathogens being the most commonly identified. These infections can damage and scar the fallopian tubes; this makes the upward travel of sperm difficult, thus reducing the chances of fertilization.

Diagnosis of Infertility

If you have been trying to conceive for over a year, including having unprotected intercourse more than 2-3 times a week, get in touch with your doctor. If your doctor suspects infertility, then they might order a panel of tests that include testing both the male and female reproductive capacity.

 

Your doctor might order a panel of tests. Most commonly ordered tests include:

 

• Semen Analysis: Single or multiple semen samples may be requested. This involves ejaculating into a clean container, and the sample collected is sent to the lab for further analysis.
• Genetic Testing: Various congenital abnormalities can be responsible for infertility in men. Genetic analysis can help rule out genetic causes of infertility.
• Hormone Testing: The maturation and development of sperms are under hormonal control. Hormone irregularities can also be responsible for infertility in men.
• Testicular Biopsy: Biopsy is used to diagnose causes of infertility and can also be used to retrieve sperm for artificial insemination.

 

Female infertility tests that your doctor can order include:

 

• HSG/ Hysterosalpingography: This imaging modality is used to look at the patency of fallopian tubes and look for any abnormalities or blocks that might be present in the fallopian tubes. It can also be used to visualize the uterus and look for uterine abnormalities if present.
• Ovulation Tests: Ovulation in females is under the control of hormones. Any hormonal abnormality, if present, can be responsible for ovulation failure and, subsequently, lack of fertilizations.
• Testing for Ovarian Reserve: Females are born with a fixed number of eggs. These eggs are released every month in females, usually on the 14th day of a 28-day menstrual cycle. Over time the quantity of eggs declines, and subsequently, menopause is achieved. Ovarian reserve testing is done to check for the number of eggs that are available for ovulation.
• The monthly set of adjustments a woman’s body makes to prepare for the potential of pregnancy is known as the menstrual cycle.
• Genetic Testing: Genetic causes of infertility are also commonly seen in females. This can help rule out genetic causes of infertility.

Treatment Options for Infertility

Once your doctor has identified infertility and its cause, the treatment will vary. Treatment options for male infertility include:

• Lifestyle Changes: As mentioned, a poor lifestyle is detrimental to the sperm. Improving lifestyle and changing certain behaviour can be very helpful. Exercising regularly can help increase sperm count.
• Medication: Your doctor may start you on medicines for infertility.
• Assisted Reproductive Technology(ART): ART involving the use of in vitro fertilizations (IVF) is popular and successful. Sometimes donor sperm, donor eggs, or frozen embryos are used in ART operations. A gestational carrier or surrogate may also be involved. A surrogate is a woman who conceives the child using the sperm of one of the couple’s partners. A gestational carrier conceives a child with an egg from one partner and sperm from the other.

 

Several other types of ART can be used like:

 

• Intrafallopian Transfer: ZIFT(zygote intrafallopian transfer) and GIFT(Gamete intrafallopian transfer) are procedures that transfer eggs after fertilizations directly into the fallopian tubes at different stages.
• Intracytoplasmic Sperm Injection: It is an additional procedure to IVF; this involves the use of a micro syringe to transfer a single sperm directly into the center of the egg. It is effective in people who have sperm-related infertility.
• IVF: It is the most commonly used type of ART available. It is the last option available for couples who want to conceive. 

What is IVF?

In Vitro Fertilization (IVF), commonly known as Test tube babies, is the most widely used mode of assisted reproduction techniques. ‘In Vitro’ means outside the human body. IVF is fertilization that occurs outside the body, most commonly in a test tube. The  egg is then transferred to the mother’s womb for further growth ad development. It is done in couples who are diagnosed with infertility (either male or female) and want to start a family.

The steps involved in an IVF procedure are:

1. Stimulation/Superovulation: This step involves the use of fertility drugs. These drugs will act on the ovary to promote egg production. Normally one egg is secreted by the ovaries; in this step, multiple eggs are secreted. Multiple eggs being is preferred because it increases the chances of a successful pregnancy. You might undergo multiple ultrasounds and hormone tests during this step.
2. Retrieval of the Eggs: This step involves a minor procedure. Your doctor will provide you with appropriate analgesia (painkiller) for the procedure. Under ultrasonographic guidance, a needle attached to a suction device is inserted through the vagina into the ovary containing the eggs. The eggs are extracted from their follicles along with the surrounding fluid. The same procedure is repeated for the second ovary. If the ovaries are dysfunctional or if the woman cannot produce any eggs, donated eggs can be used.

2. Insemination and Fertilizations: The isolated eggs from the mother and sperm from the father are placed together; this is called insemination. Only the best quality eggs are selected for this procedure. Eggs and sperms are stored in a controlled environment to ensure viability. Fertilizations will occur within a few hours of insemination. Your doctor can try ICSI or intracytoplasmic sperm if the chance of fertilization is low.

3. Embryo Culture: An embryo is the result of a continued division of a egg. Once fertilization has occurred, the embryo is kept in a controlled environment for a few days to ensure proper growth and development.
4. Transfer of Embryo: After a few days, the embryo is transferred to the mother’s womb. This is done by the doctor using a catheter containing the embryos. The catheter is passed through the vagina to the uterus. Once the transfer of embryos is complete, if implantation occurs, it results in a successful pregnancy. This step has a high failure rate; hence, multiple embryos are transferred to increase the chances of a successful pregnancy. The drawback of this step is that it results in a higher incidence of multiple pregnancies. Additional embryos are frozen for the future.

Risks Associated with IVF

IVF works wonders for couples who are unable to conceive. Since it is an artificial method, it comes with its own set of disadvantages. If you have recently undergone an IVF procedure or are planning to, please contact your doctor for further information. A few risks of IVF are:

• Multiple Pregnancies: The transfer of multiple embryos increases the chances of numerous embryos getting implanted. Any pregnancy that has multiple fetuses has the risk of going into early labour and low birth weight babies.
• Ovarian Hyperstimulation Syndrome (OHSS): The use of fertility drugs causes the ovaries to undergo hyperstimulation. This results in the ovaries being swollen and painful. Symptoms associated include abdominal pain, bloating, nausea, vomiting and diarrhoea. If you face any of these symptoms, get in touch with your doctor for further care.
• Ectopic Pregnancy: Any pregnancy where implantation of the embryo occurs at a site other than the endometrium is called an ectopic pregnancy. A pregnancy with a fetus at any site other than the endometrium is not viable and will not grow and increases the risk for the mother.
• Miscarriage: Although IVF itself doesn’t increase the risk of miscarriage, advanced maternal age is associated with an increased risk of miscarriage.

IVF can be a physically, mentally and financially stressful aspect with a high chance of success and a significant chance of failure. However, if you are eager to start a family and have been unable to conceive, let your doctor help you find the best solution for you.

FAQs:

1.   Is IVF harmful?

A lot of couples these days are opting for IVF now. Any surgical or invasive procedure carries a certain risk associated with it. However, overall the risk of complications during egg collection is relatively minimal since it is ultrasound-guided. OHSS has a certain amount of risk with it, but the incidence of severe OHSS is relatively low.

2.   Is the incidence of multiple pregnancy high?

Yes, IVF has been associated with multiple pregnancies, and the incidence is as high as 30%. The more embryos used, the higher the chance of multiple pregnancies.

3.   What is the success rate of IVF?

Around the globe, the success rate has been recorded from 30-50%.

 

REFERENCES:

1. https://www.acog.org/womens-health/faqs/having-a-baby-after-age-35-how-aging-affects-fertility-and-pregnancy
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5922227/
3. https://www.cdc.gov/reproductivehealth/infertility/index.htm

 

Written by Dr Nachiket Brahmankar

Dr Nachiket is a fully registered MMC Doctor, practising as a general physician at Apollo Clinics. In his free time, he loves to explore new hiking trails and read books.

Reviewed by Dr Manavi Raj

Dr Manavi is a healthcare professional with a Bachelor of Dental Surgery from Rajiv Gandhi University of Health Sciences, Bangalore. She has a diverse history of working in healthcare, writing and social media marketing. Outside of work, she enjoys dabbling with paints and loves the outdoors.