Understanding Infertility

Infertility is more common than you think it is and affects 1 in 8 couples worldwide. Infertility affects men and women equally. If you or someone you know is struggling to get pregnant, 

READ ON to understand and learn about Infertility.

Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS) is a hormonal disorder common among women of reproductive age. Worldwide, it affects about 8-13% of women – about one in 10 – from when their periods begin to when they reach menopause. In India, roughly 3 in 10 women have PCOS.
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What is the cause of PCOS?

The exact cause of polycystic ovarian syndrome is unknown. Genetics, hormones and lifestyle factors all play a role in PCOS. Women with PCOS are more likely to have a mother, sister or aunt with PCOS.

What are the signs and symptoms of PCOS?

  • irregular periods or no periods (without medicines)
  • hair growth on face, stomach and back
  • loss or thinning of scalp hair
  • oily skin, acne (pimples) that can be severe
  • Darkening of skin- along neck creases, in the groin and underneath breasts
  • easy weight gain and difficulty losing weight
  • emotional problems (anxiety, depression, poor body image)
  • difficulty getting pregnant

Symptoms of PCOS vary from woman to woman, and also change over time. Some women have very few and mild symptoms, while others have more severe and a wider range of symptoms.

How is PCOS diagnosed?

Medical history, examination, blood tests and ultrasound are used to diagnose PCOS. Just an ultrasound report showing or mentioning polycystic ovaries does not mean that you have the condition.

 A PCOS diagnosis requires 2 out of the following 3 criteria:

  1. irregular, infrequent periods or no periods at all 
  2. an increase in facial or body hair and/or blood tests that show higher testosterone levels than normal 
  3. an ultrasound that shows polycystic ovaries

 

What are the health issues related to PCOS?

Many women with PCOS have difficulty managing their weight. There is a tendency to gain weight easily and weight loss is difficult. Some women with PCOS maintain a normal weight but they still face fertility challenges, increased androgens and an increased risk of diabetes and cardiovascular disease. Depression and anxiety are more common in women with PCOS.

Women with PCOS often find it hard to conceive naturally. The hormonal imbalance prevents the regular cyclical development and release of a mature egg (anovulatory infertility).

There is an increased risk of developing diabetes, high blood pressure and cardiovascular disease (heart disease, stroke). These risks can be reduced with an active lifestyle, healthy diet and weight reduction. In women with long periods of amenorrhoea, the lining of the womb (endometrium) can thicken and this can increase the risk of endometrial cancer.

Is it possible for women with PCOS to get pregnant?

Yes. Having polycystic ovarian syndrome does not mean that pregnancy is just not possible. PCOS is one of the most common, but treatable, causes of infertility. 

What are the treatment options for women with PCOS who are trying to get pregnant? 

Losing weight. Healthy diet and regular physical activity can help regularise the menstrual cycle and improve fertility. 

Ovulation induction. After ruling out other causes of infertility, ovulation induction with medicines is usually the first step.  

Assisted Reproductive Technology (ART). Intrauterine insemination (IUI) may be an option if ovulation induction with planned relations does not work or if there is an associated male factor. People often search online for ‘egg retrieval IVF’ but medically, IVF/ICSI is a process which involves egg retrieval and embryo transfer that may be required in case of multiple failed IUI or associated blocked tubes or severe male factor.

Endometriosis

The tissue lining the inside of the womb (uterus) is known as endometrium. When this tissue is found outside the uterus, the condition is known as endometriosis. Endometriosis affects 1 in 10 women of reproductive age.

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What causes endometriosis?

The exact cause of endometriosis symptom is not known. The possible causes include:

  • Problems with menstrual flow. Retrograde (backward) menstrual flow is the most likely cause of endometriosis. Some of the endometrial tissue shed during the period flows through the fallopian tubes into the pelvis.
  • Genetic factors. Endometriosis is known to run in families.
  • Immune system problems. A faulty immune system may fail to destroy endometrial tissue growing outside of the uterus.
  • Hormones. The hormone estrogen appears to promote endometriosis. 
  • Scar endometriosis (Surgery). During a surgery to the abdominal area, such as C-section or hysterectomy, endometrial tissue could be picked up and moved unknowingly to the incision site leading to scar endometriosis in some women. 
 



What are the symptoms of endometriosis? 

  • Pain is the most common endometriosis symptom. The varying types of pain are-
    • Very painful menstrual cramps
    • Chronic (long-term) lower back pain
    • Pain during or after sex (dyspareunia)
    • Abdominal pain
    • Painful bowel movements or pain when urinating during menstrual periods. In rare cases, there may be blood in stool or urine.
  • Bleeding or spotting between menstrual periods
  • Heavy bleeding
  • Inability to conceive (Infertility)
  • Digestive problems like diarrhoea, constipation, bloating or nausea, especially during menstrual periods
 

Many women have no symptoms at all.


How does endometriosis affect fertility?

Endometriosis can affect fertility in several ways; adhesions leading to scarring of fallopian tubes and distortion of pelvic anatomy, inflammation of the pelvic structures, altered immune system, altered egg quality, impaired implantation.


How is it diagnosed?

If endometriosis is suspected based on the medical history and physical examination, your Fertility Physician will most likely advise an ultrasound. Ultrasound may show endometriotic cysts (endometriomas) on the ovaries or nodules of deep endometriosis, but not always. Ultrasound cannot detect superficial (surface) endometriosis. A definitive diagnosis can only be made at laparoscopy or open surgery. 


How is infertility associated with endometriosis treated?

Not all women with infertility and suspected mild endometriosis need laparoscopy. Factors such as the woman’s age, duration of infertility, any pain symptoms etc must be considered. If pain is a concern, laparoscopy and surgical treatment may be important. Laparoscopy and possible laparotomy (large incision) are recommended when moderate or severe endometriosis is suspected and no other cause of infertility has been found. 


Medical therapy is effective for pain relief which is the most common endometriosis symptom, but there is no evidence that medical treatment with birth control pills, progestins, GnRH analogs, or danazol improves fertility. Medical treatment before or after surgery may unnecessarily delay further fertility therapy. 


‘Expectant management’ or ‘watchful waiting’ is an option for younger women (with no other infertility factors) after surgery for endometriosis. As an alternative to expectant management or if pregnancy fails to occur within a reasonable time frame, IUI or IVF/ICSI may be offered. Success rates with IVF/ICSI in women with endometriosis  are similar to those for couples with other causes of infertility. Success rates for ART procedures vary greatly depending on the woman’s age.

Problem with the Tubes

The fallopian tubes are delicate muscular tubes, one on each side, extending from the uterus toward the ovaries. The egg once released from the ovary (at ovulation), travels through the tube toward the uterus. The sperm travels up from the uterus through the tube toward the egg. Fertilization between the egg and the sperm takes place in the tube and then the fertilized egg travels to the uterus to get implanted. If any part of the fallopian tube/s is damaged or blocked, it is difficult for pregnancy to occur naturally.

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Here are 10  important facts about tubal factor infertility

  1. Tubal disease is one of the commonest causes of female infertility.
  2. Risk factors for tubal disease include a history of pelvic infection (sexually transmitted infection), genital tuberculosis, previous ectopic pregnancy, endometriosis, history of appendicitis (especially ruptured appendix), or previous tubal surgery. 
  3. Normal fallopian tubes are not seen on ultrasound. However, if the tubes are dilated (hydrosalpinx) they sometimes can be seen on ultrasound. 
  4. The commonest test used to evaluate the fallopian tube is the hysterosalpingogram (HSG).
  5. Fallopian tube blockage is usually found in the proximal (the portion near the uterus) or at the distal (fimbrial) end. Obstruction in the middle part of the tube can be present but is relatively uncommon. 
  6. In some cases, proximal tubal occlusion (PTO) can be treated with tubal canulation at hysterolaparoscopy.
  7. Distal tubal blockage often results in the tubes dilating and appearing like a balloon (hydrosalpinx). These patients are usually advised IVF/ICSI. Removal of the hydrosalpinges (salpingectomy) is often recommended to maximize the chances of success with IVF.
  8. Intra uterine insemination is NOT recommended in tubal factor infertility.
  9. Patients with tubal disease are at risk for a tubal pregnancy regardless of how they conceive. This can happen even with IVF.
  10. IVF/ICSI success rates are among the best for those with only tubal factor infertility (and no other associated infertility factor).

Low Egg reserve

Women are born with all of the eggs they will ever have in their life. Throughout a woman’s reproductive life, every month, the body recruits a group of follicles (each with an immature egg inside) that have the potential to respond to hormones, grow and ovulate. Usually, a woman ovulates one egg per month. The eggs that do not get selected to ovulate undergo atresia and this process repeats cycle to cycle (unless a pregnancy occurs) till menopause.

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The supply of eggs within the ovaries is referred to as ‘ovarian reserve’. Diminished or poor ovarian reserve means having a low supply of eggs. With age, ovarian reserve  declines. Certain factors can accelerate this decline and many times we see young women with a poor reserve as well.

What are the causes of diminished ovarian reserve?
  • Advancing age
  • Cigarette smoking
  • Genetic abnormalities (like Fragile X, Turner syndrome)
  • Cancer treatments (radiation/chemotherapy)
  • Ovarian surgery, such as for endometriosis
  • Idiopathic (no apparent cause)


What impact does age have on ovarian reserve?
Ageing results in a natural decline in a woman’s ovarian reserve. There is a decline in the quantity as well as the quality of eggs with age. A woman’s fertility peaks in her 20s and starts to decline in her 30s, especially after age 35. For many years, it was thought that the uterus is also affected by the aging process, but today it is clear that the decline in fertility with age  is mostly due to the aging egg. The inability to produce healthy, viable eggs often results in lower pregnancy rates as well as higher rates of miscarriage in women above 35. 

How is a low ovarian reserve diagnosed?

Women with poor egg reserve usually do not have any specific symptoms. Some women may notice a shortened menstrual cycle, such as from 28 days to 25 days. But for the most part, poor reserve is diagnosed only after ovarian reserve testing. The reliable tests for ovarian reserve include transvaginal ultrasound for antral follicle count (AFC) and blood test for anti-Müllerian hormone (AMH). 

Is it important for all women struggling to conceive to get their ovarian reserve tested?
Ovarian reserve testing is an important part of the fertility evaluation of an infertile couple. The test results help diagnose poor egg reserve and decide further course of action. For women with a low reserve, the window of opportunity to conceive may be shorter and this may encourage couples to act now and pursue treatment options with better success rates.

Azoospermia

Azoospermia refers to the condition in which there are no sperm in the ejaculate. Most men with zero count have normal libido, normal sexual function, and their semen looks completely normal too. The diagnosis can only be made by a semen analysis.

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What are the causes of Azoospermia?

Azoospermia can be “obstructive,” where there is a blockage preventing sperm from entering the ejaculate, or it can be “nonobstructive” when it is due to decreased or absent sperm production by the testis.

Causes of Obstructive Azoospermia-
  • Congenital bilateral absence of the vas deferens (CBAVD)
  • Trauma
  • Ejaculatory duct obstruction
  • Infections
  • Previous surgery
  • Vasectomy

Causes of Non Obstructive Azoospermia-
  • Hormone imbalance
  • Varicocele
  • Medications
  • Ejaculation issues
  • Genetic conditions
  • Cancer/Chemotherapy/radiation

How is azoospermia diagnosed?

Azoospermia is diagnosed when, on two separate occasions, the semen sample shows no sperm when examined under a high-powered microscope following a spin in a centrifuge. 

What are the next steps?

Your Fertility physician may refer you to a Urologist for a physical examination for checking for the size of the testicles, presence of the vas deferens, tenderness or swelling of epididymis, the presence or absence of a varicocele, and any blockage of the ejaculatory duct.

The following tests may be advised-

  • Testosterone and FSH levels
  • Genetic testing
  • TRUS (Transrectal USG) 

The testicular size, any signs of obstruction on examination and the FSH level are helpful for distinguishing between obstructive and non-obstructive azoospermia. 

What are the treatment options? 

The treatment needs to be individualised based on the physical findings, blood test results and the wife’s age and reproductive function. Depending on the suspected causes, there are different treatment options. In some cases, treatment for hormonal abnormalities can increase sperm production. If there is a blockage (or history of vasectomy), reconstruction might be an option. In some men, surgery for varicocele can be considered. In many others, the best option is to attempt surgical retrieval of sperm that could be used for ICSI. It is very important that surgical sperm retrieval is performed by physicians with proper training, expertise and experience to optimize outcomes. 

What procedures are used to retrieve sperm in case of azoospermia?

The different surgical sperm retrieval techniques are percutaneous epididymal sperm aspiration (PESA), testicular sperm extraction (TESE), microsurgical epididymal sperm aspiration (MESA) and others. The choice is usually based on patient factors and the preferences of the reproductive endocrinologist. For men with obstructive azoospermia, sperm production is unhampered and sperm are usually found by using the above techniques. For men with nonobstructive azoospermia, TESE or microTESE is usually advised to go along with intracytoplasmic sperm injection (ICSI).

Low Sperm Count

Oligoasthenoteratozoospermia (OAT) is a common cause of male subfertility. In simple words it means- low count (oligozoospermia), low motility (asthenozoospermia) and abnormal morphology (teratozoospermia). It is diagnosed by a semen test. The 3 abnormalities can be found separately or together in the same semen sample.

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Semen analysis

A semen analysis is an important part of the evaluation of any couple seeking treatment for fertility problems.

Normal values of semen variables according to the WHO (2020):

Volume: 1.4 ml or more
Sperm concentration: 16 million spermatozoa/ml or more
Total sperm count: 40 million spermatozoa per ejaculate or more
Motility: 30% or more (forward progression) or 42% or more (total motility)
Morphology: 4% or more normal forms

The semen analysis needs to be done on at least two occasions and if one analysis shows abnormality, it may need to be examined more than twice.

What are the causes of OAT?

  • Idiopathic- in about 30% of cases, the cause is unknown
  • Endocrine problems- like hyperprolactinemia, thyroid disease, hypogonadotropic
    hypogonadism)
  • Obesity
  • Varicocele
  • Infection
  • Genetic conditions like Klinefelter’s syndrome
  • Cancer and its treatments
  • Previous surgery- such as testicular surgery, surgery for undescended testes and inguinal hernia repair
  • Environmental
  • Lifestyle- like heavy drug and alcohol use, using tobacco or vaping, use of Anabolic steroids
 
One of the most common causes of low sperm count is incomplete or improper sample collection.

Sperm counts also often fluctuate. Because of this, it is advisable to check two or more semen samples over time to ensure consistency between samples.

What are the treatment options?

The underlying cause, if any, needs to be treated. For example, men with endocrine problems and infections should be treated for their condition. It is important to follow a healthy lifestyle, avoid alcohol, tobacco and drugs and avoid excessive heat in the scrotal area.

Although a variety of vitamin supplements have been studied, antioxidants or vitamins usually do not lead to dramatic improvements in sperm count.

It is important to understand that the effect of any treatments or lifestyle changes will reflect in the semen analysis only after 2 to 3 months.

If OAT persists or if there are other associated infertility factors, assisted reproductive technology (ART) like intrauterine insemination (IUI), in vitro fertilization (IVF), or intracytoplasmic sperm injection (ICSI) may be needed.

People commonly search for ‘egg retrieval IVF’ online, but egg retrieval is only one part of the IVF process. Go to ‘A step by step look at the IVF process’ to understand IVF better.

Is it impossible to achieve pregnancy with low sperm counts?

Low sperm count does not mean that pregnancy is impossible to achieve naturally. It may just take more time than originally expected, and it may require seeing a Fertility Physician to see if medication may help and to know your treatment options.