Infertility – Why?
by Rupal Shah
Infertility is defined as “Failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.” Approximately 80 - 85% of couples will conceive within one year of marriage, if they have regular unprotected sex. One in 6 couples have problems leading to infertility. Studies indicate that out of all cases of infertility 40% are due to female conditions, 40% are due to male problems, while 20% are due to a combination of both male and female factors or unidentified factors (Unexplained Infertility). Primary infertility When a woman is unable to bear a child, she would be classified as having primary infertility. Secondary infertility It's called secondary infertility, when a woman is unable to get pregnant after having at least one pregnancy in form of miscarriage or pre-term/fullterm delivery of a baby. Female Infertility There are many possible causes of infertility. Unfortunately, in about one-third of cases, no cause is ever identified. ovulation disorders Problems with ovulation are the most common cause of infertility in women. Ovulation disorders can be due to: • PCOS (polycystic ovary syndrome) - A woman's ovaries function abnormally due to abnormal reproductive hormonal levels. She may also have abnormally high levels of androgen. About 5% to 10% of women of reproductive age may have this problem. • Hyperprolactinemia - If a woman’s prolactin hormone level is high, it can affect her ovulation and fertility. • Poor egg quality /old age patients - eggs which are damaged or having genetic abnormalities, cannot sustain a pregnancy. • Overactive thyroid gland /Underactive thyroid gland. • Premature ovarian failure - When a woman's ovaries stop working before she is 40. • Patients who are on treatment for some chronic conditions, such as AIDS or cancer. Problems in the uterus or fallopian tubes The egg travels from the ovary to the uterus (womb), through fallopian tubes. Fertilisation of egg and sperm takes place in the fallopian tube and fertilized egg (embryo) grows in the uterus. If there is something wrong in the uterus or fallopian tubes, a woman may not be able to conceive naturally. Causes of blocked fallopian tubes: • Pelvic Inflammatory Disease (PID) leading to salpingitis and hydrosalpinx • ectopic pregnancy • endometriosis • Tubal ligation surgery • Adhesions following abdominal surgery • Genital Tuberculosis (still common in developing countries like India). Uterine causes: • Uterine fibroids can distort the endometrial cavity making it difficult for implantation • Intrauterine adhesions from previous surgery or infection of the endometrium. • Severe defect in uterine shape/absence of uterus by birth Male infertiLity Semen Quality Abnormal semen is responsible for about 75% of all cases of male infertility. The following semen problems are possible: • low sperm count (low concentration) - Sperm count of 40 million to 300 million per mililitre is the normal range. Counts of 20 million/Ml or more may be fine if motility and morphology of sperm are normal. Count below 10 million/Ml is considered severe male infertility. • No sperm (azoospermia) - when the man ejaclates and there is no sperm in the semen. • low sperm motility- The sperm cannot "swim" or cannot do progressive movement competently. • Abnormal sperm - The sperm has an unusual shape, making it more difficult to fertilize an egg. Sperm must be of the right shape and be able to travel rapidly and accurately towards the egg. If the sperm's morphology (structure) and motility (movement) are abnormal, it is less likely to reach the egg and fertilize it. Causes of abnormal semen parameters 1. Testicular infection: If infections like Mumps occurs after puberty, inflammation of the testicles may affect sperm production. 2. Treatment of Testicular cancer: in form of surgery, chemotherapy or radiotherapy 3. Surgery: surgery on the testicles may interfere with their blood supply, thus reducing the growth and maturation of sperm. Surgery to the lower part of the bladder or prostate can lead to retrograde ejaculation. 4. Overheating the testicles: Frequent saunas, hot tubs, very hot baths, or working in extremely hot environment can raise the temperature of the testicles. Tight clothing may have the same effect on some people. 5. Ejaculation disorders: For some men it may be difficult to ejaculate properly. Men with retrograde ejaculation ejaculate semen into the bladder. If the ejaculatory ducts are blocked or obstructed the man may have a problem ejaculating appropriately. 6. Varicocele: This is abnormal dilatation and tortuosity in the veins of the scrotum that may cause impaired sperm production 7. Undescended testicle (Cryptorchidism): One (or both) testicle fails to descend from the abdomen into the scrotum during intra-uterine development of a baby. 8. Absence of the vas deferens: The duct that transports the sperm from the testicles to the penis is absent. This issue is usually associated with cystic fibrosis. 9. Hypogonadism: Male hormone Testosterone or other related hormonal deficiency can lead to impaired sperm production 10. Genetic abnormalities: A man should have an X and Y chromosome. If he has two X chromosomes and one Y chromosome (Klinefelter's syndrome), there will be an abnormal development of testicles, low testosterone, and a low sperm count (sometimes no sperm at all). Microdeletion of arm of y chromosome and a genetic medical condition known as cystic fibrosis can lead to severe male infertility. Cystic fibrosis is a chronic disease that affects organs such as the liver, lungs, pancreas, and intestines. Males with cystic fibrosis commonly have a missing or obstructed vas deferens. 11. Hypospadias: The urethral opening is at the underside of the penis, instead of its tip. This abnormality is usually surgically corrected in childhood only. 12.Medical diseases: Cushing's syndrome, Diabetes, Thyroid disease. 13.Medications: Sulfasalazine used in rheumatoid arthritis, Anabolic steroids, often taken by bodybuilders and athletes, Chemotherapy (anti-cancer treatment); Illegal drugs like marijuana and cocaine, excessive smoking and alcohol consumption can also lower a man's sperm count.