Popular Infertility Treatments in Men and Women

 

What is Infertility?

Infertility refers to the inability of a couple to conceive. More simplistically, it refers to the inability of the woman to become pregnant. Medically speaking, when the couple is unable to conceive or produce children even after 1 year of unprotected sexual cohabitation is called infertility. For women over 35 years of age, the period is 6 months of cohabitation. Women who conceive but are unable to carry the pregnancy till the period of viability may also be termed infertile.

Primary infertility refers to a complete lack of conception. Secondary infertility is for those women who had a successful pregnancy in the past but are unable to conceive now.

The causes are varied- physical, congenital, diseases, drugs, immunological or even psychological. It may involve both the partners, the male and the female. According to studies on reproductive health, half of the times men are responsible, while for the rest half, women are to be held responsible.

Causes of Male Infertility

A normal sperm count ranges from 15 million to 200 million sperms/ml. A low sperm count is called oligospermia (less than 15 million/ ml). Absence of sperm production is called azoospermia.

However, a sperm count in the normal range does not rule out infertility.

Sperm morphology and motility are equally important.

Movement of the sperm includes both, the wiggling movement of the tail of the sperm along with the peristaltic movements of the male genital tract, especially epididymis.

A variety of risk factors, medical conditions, and medications can also affect fertility.

Risk factors

1. Older age
2. Smoking cigarettes
3. Heavy alcoholism
4. Obesity
5. Exposure to pesticides, herbicides and other heavy metals in contaminated food.

Medical conditions responsible for Infertility in Men

1. Retrograde (Or reverse) ejaculation
2. Varicocele (Swelling of the venous plexus around the testicles)
3. Undescended testis in the scrotum.
4. Auto-immune antibodies against sperms.
5. Inadequate testosterone production.

Medications and drugs

Medications and drugs which affect male fertility include:

• Chemotherapy and radiotherapy as a part of cancer treatment.
• Drugs used in inflammatory diseases like rheumatoid arthritis, ulcerative colitis and Crohn’s’ Disease including sulpha drugs.
• Calcium channel blockers (verapamil, diltiazem, etc) which are used in heart diseases, hypertension.
• Tricyclic (typical anti-depressants)
• Anabolic steroids, which are used for improving athletic performance.
• Hormonal imbalances leading to delayed puberty.
• Abusing drugs such as cocaine and marijuana.
• Any of the factors, in combination or together, may lead to the development of infertility.

Causes of female infertility

Let us understand the process of ovulation, fertilization, implantation and the development of the embryo.

• Ovulation: Release of the mature ova from the ovary in the middle of the 28-day cycle.
• Fertilization: Union of the sperm and ovum in the fallopian tube. The sperm has to traverse the vagina, cervix and the uterus to finally reach the ampulla of the fallopian tube.
• Implantation: Implantation refers to the attachment of the blastocyst (about 250 cells) into the endometrium (lining of the uterine cavity)
• At birth, the ovaries of a female contain about 1-2 million immature ova. By the time, the female reaches puberty, only 4-5 lac ovarian follicles remain in the ovary. Around 1000 follicles undergo regression every month. As a result, in the normal reproductive span of a female (15-45 years), about 500 ova are released.
• Normally, in a normal menstrual cycle, one ovum is released on the 14th day of the cycle. Fertilization occurs within the next 12-24 hours. Implantation begins by the 21st-22nd day when the blastocyst (a zygote after divisions which has resulted in 32 cells) implants into the endometrium. Implantation is completed by the 24th day.

A variety of factors interfere with these normal process, which may contribute to the development of infertility in females.

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Risk factors

Risk factors for female infertility include:

1. Older age
2. Smoking cigarettes
3. Heavy alcoholism
4. Obesity
5. Sexually transmitted infections (STIs) which lead to fibrosis of the genital tract.

Medical conditions:

The medical conditions which can lead to infertility in women include:

• Ovulation disorders: Ovarian cysts or teratomas or hormonal imbalances leading to ineffective ovulation.
• Pelvic inflammatory disease (PID), which causes scarring and pre-disposes to infections.
• Endometriosis: Normal endometrium in an abnormal location other than the uterus. Know more about Endometrial Cancer
• Uterine fibroids: They refer to hypertrophy or increased whorls of smooth masses in the uterus.
• Premature ovarian failure, when the ovarian reserve of ova is finished.
• Scarring or adhesions from a previous surgery

Medications and drugs:

Certain medications and drugs that can affect female infertility include:

• Prolonged use of Non-steroidal anti-inflammatory drugs including aspirin, ibuprofen.
• Antipsychotic and anti-depressant medications.
• Abusing drugs such as cocaine and marijuana.
• Chemotherapy and radiotherapy as a part of cancer treatment.

Ovulation problems are responsible for about 25% of the infertility issues seen in couples. An irregular or absent menses warrants medical attention for infertility.

Infertility Testing

There are various indications for which both men and women may see a fertility expert. It may be primarily because, even after sexual activity, the couple would be unable to conceive.

Men:

Men should consult a medical professional if one of the following troubles them:

1. Erectile dysfunction (ED)
2. Delayed or retrograde ejaculation.
3. Low sex drive
4. Impotency
5. Pain/Swelling in the groin area
6. Previous surgery in the genital area

Your doctor will first take your medical history. During this Following a thorough medical history and appropriate medical examinations, a semen analysis is likely to be performed. The sperms will be checked for the adequacy of number, morphology and motility.

Additional testing may include:

1. Hormone assays
2. Ultrasonography of the genitals
3. Genetic testing

Women:

• After 30 years of age, fertility usually starts decreasing. Women below 35 years should visit after 12 months of trying cohabitation while those above 35 years should pay a visit after 6 months.
• Present medical history, sexual history and presence of other illnesses or chronic diseases will be taken into account before proceeding for further investigations.
• An abdominal examination for checking the pelvic adequacy, PID, fibroids or endometriosis may be done.
• An ultrasound may also be used to examine the ovaries and uterus.

Other testing includes:

Contrast Hysterosalpingography: X-ray of the pelvic area by injecting a contrast dye into the fallopian tubes to evaluate the fallopian tubes and uterus.

• Laparoscopy, which may be used to visualize the pelvic viscera along with the internal reproductive organs.
• Ovarian reserve testing: Hormone tests to check for the level of 2 main hormones: Follicle-stimulating hormone (FSH) and LH (Luteinizing hormone).

Infertility treatments

The type of infertility treatment depends upon various factors, biological, personal, affordability and availability in the given healthcare-setting. They include:

1. The cause of infertility. In 10-15% cases, the cause is unknown, also known as primary idiopathic infertility.
2. Age of the male and the female couple.
3. Time since which they have been trying to conceive
4. Health status of the couple.
5. Personal preferences of the couple.

Assisted reproductive technologies may prove to be a boon for such couples. There are two primary modalities: In-vitro (fertilization outside the body) or in-vivo (fertilization within the body) methods.

Infertility Treatments: In-vitro (IVF)

If the fertilization occurs outside the body of the female and after it, the embryo is transferred into the uterus or fallopian tube of a surrogate mother or same mother, this is called embryo transfer. Two types of in-vitro fertilization:

• ZIFT (Zygote-intra-fallopian tube transfer): The zygote or early embryo up to the 8 cell stage is transferred into the fallopian tube of the surrogate or same mother. This is called a ZIFT.
• IUT (Intra-uterine transfer): If more than 8 cell-stage (commonly up to 32 cell stage) are transferred into the uterus, this is called as IUT.
• ICSI (Intra-cytoplasmic sperm injection): The sperm is directly injected into the cytoplasm of the ova via a micro-needle. This is referred to as ICSI.

The embryos are generally allowed to develop outside the body into appropriate culture media. They can be frozen for implantation at a later stage.

Or after development up to the 32 cell stage and checking for the genetic makeup ( to rule out genetic abnormalities), the embryos are inserted into the uterus.

ICSI is further divided into percutaneous epididymal aspiration or direct testicular aspiration.

Percutaneous Epididymal Sperm Aspiration (PESA):

It is indicated when the vas deferens (a connecting tube) is absent or blocked. In cases of infections as well, there may be obstruction and inflammation leading to a seminal fluid which does not contain sperms.

Testicular Sperm Aspiration (TESA):

It is done usually when the epididymis itself has lost its patency or does not contain sperms.

Assisted Hatching:

At times the zona pellucida (a protective covering around the fertilized ovum .i.e the zygote may be too thick. This prevents implantation. It can be overcome by assisted hatching.

A hole is made in the wall of the embryo using a special needle or a chemical or a laser beam. The embryo can now be transferred into the uterus for implantation. This is especially used when there have been previous instances of repeated implantation failure.

Freezing:

Either the embryo may be frozen (embryo freezing) or the oocyte may be frozen (oocyte-freezing) to be used at a later stage.

Usually, during the in-vitro techniques, 4-5 embryos are allowed to mature up to the 32 cell stage and one or two are implanted int eh uterus. The rest are frozen, which can be used later, in case of failure of development.

Oocyte freezing is still under research as oocytes reportedly get destroyed during freezing.

Seminal fluid and testicular tissue may be frozen as well. This is indicated for those men who have a problem giving sperms on the day of retrieval of the oocyte. Secondly, when the seminal fluid or the epididymis lacks sperms, the sperms or the testicular tissue may be frozen to be used at a later stage. It can also be used in men who have the testicular disease and would require removal of testis. It may also be employed for patients who would undergo chemotherapy or radiotherapy which would damage the sperms.

In-vivo Fertilization

If the fertilization process occurs within the body of the female (mother/surrogate) via natural or artificial methods, this is known as in-vivo fertilization. This method tends to fertilize the ova in the fallopian tube while mimicking the natural process of fertilization.

The two widely employed methods are:

1. GIFT (Gamete intra-fallopian tube transfer): Transfer of an ovum collected from the ovary into the fallopian tube of the same female or of a female who can provide an appropriate environment for fertilization is called GIFT.
2. AI (Artificial Insemination): If the male is unable to inseminate the semen into the vagina, then the semen is artificially introduced either into the cervix or into the uterus of the female (intrauterine insemination)

The main complications include miscarriage (the pregnancy may be aborted prematurely), multiple pregnancies (if all the implanted embryos survive), ectopic implantations (implantation at other sites instead of the uterus, most commonly in the fallopian tube) and increased risk of prematurity.

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