Infertility in medical language is the inability to conceive even after a year or so of unprotected sex. Through a wide spectrum word in itself, the term infertility is quite a common problem these days. UCLA Health had reported that an estimated 15% of couples have trouble conceiving. Globally 48.5% of couples experience infertility, with 1 in every 4 couples in developing countries affected by infertility. The American Society for Reproductive Medicine has reported that, in general, fertility starts diminishing by their late 20s and 30s, with the declining rate more marked after the age of 35. Apart from the conceiving issues, multiple miscarriages or stillbirths is also counted as infertility. In comparison, sperm quality in men is generally not affected till above 65 years of age.
What is the pathophysiology of infertility?
The main elements of the female reproductive system are the vagina, uterus, fallopian tubes and ovaries. The vagina is a muscular hollow tube extending from the vaginal opening to the uterus. It serves as the collecting point of semen during intercourse, with the baby’s pathway leaving the woman’s body during childbirth. The vagina is connected with the uterus of the reproductive system. Shaped like an upside-down pear, the uterus and housing the fetus hold the road to the ovaries. The fallopian tubes are present at the upper corner of the uterus that connects the uterus with the ovaries. The ovaries are responsible for producing, storing and releasing the eggs through the fallopian tubes into the uterus.
The work of the female reproductive system is to produce the eggs in the ovaries, fertilize it through sexual intercourse, protect it till it is fully developed and then push the fetus out of the body by means of childbirth. Any obstruction or defect to either or all of the units creates a barrier in the reproductive cycle resulting in infertility.
Causes of infertility
Infertility is a broad spectrum word, including a lot of dysfunctions and disorders in its chronology. Some of the most important causes of infertility are-
Failure to ovulate is one of the most common fertilizer issues occurring in around 40% of women. A variety of gynaecological conditions like PCOD (Polycystic Ovary Syndrome) and POI (Primary Ovarian Syndrome) are said to be responsible for this condition. But variables like age, lifestyle factors (like obesity and substance abuse) with endocrine disorders further add to the problem.
Problems in the Menstrual Cycle
The menstrual cycle of a female is the process in which the female hormones stimulate the ovaries to release an egg, thicken the uterus lining to support the egg in case of pregnancy and then discard the lining if there is no pregnancy. Menstrual irregularities like amenorrhea (absent periods), oligomenorrhea (infrequent periods), menorrhagia (heavy periods), and dysmenorrhea (painful periods with severe menstrual cramps) are some of the main factors affecting female infertility. Apart from this, polymenorrhea (frequent periods occurring less than 21 days apart), irregular cycles and shortened cycles are some of the other menstrual defects that can cause fertility issues in the long run.
Endometriosis (extra intrauterine line leading to fallopian tube blockage) and polyps (non-cancerous growths on the insides of the uterus) are some of the common structural problems interfering with the fertility process in females. Apart from these, size and scarring of the uterus also affect implantation or fetal growth during the gestation period of pregnancy.
Gonorrhoea and chlamydia are some of the sexually transmitted diseases caused by unprotected sex or transmitted through sexual contact with an infected partner. These diseases, if left untreated, can cause inflammation of the pelvic structure leading to uterus scarring or scaring-induced blockage of the fallopian tubes. Untreated syphilis can harm the fetus leading to stillbirth, while HPV (Human Papillomavirus) can reduce the amount of cervical mucus leading to problems in the transfer of the egg for implantation.
Autoimmune conditions like rheumatoid arthritis and Lupus inflame the uterus and lead to conceiving problems through their inflammatory conditions. PCOD interferes with the development of ovarian follicles and the release of the eggs during ovulation. Fibroids interfere with the position of the cervix and uterus by blocking the fallopian tubes and interfering with the blood flow to the uterus, all of which affect fertilization or implantation significantly.
Impact of Infertility
The impact of infertility has high reaching consequences. A succession of miscarriages and stillbirths can impact a woman’s health to a vast extent. But the damage does not limit itself to its physical aspect. Infertility and its ensuing complications affect the relationship between couples and their married life, affecting their mental health. The International Journal of Reproductive Biomedicine has reported that infertility is one of the primary reasons for divorce in couples. Apart from this, studies have also proved that 60% of infertile individuals face psychiatric issues with significantly higher levels of anxiety and depression than fertile individuals. The statistics are staggering, with around 41% of infertile women having anxiety and 87% having anxiety.
After the infertility diagnosis has been done and the underlying problem pinpointed, the next step is to evaluate the treatment options. Both Medications and surgical options can be of help depending on your condition. They are followed by Assisted Reproductive Technologies (ART) as the final option.
Medications are of primary importance in thyroid conditions where regulating the hormonal functions restores the reproductive hormones. Apart from these, some other medications are
Clomiphene (Clomid) is a Phosphodiesterase inhibitor that increases the hormones responsible for egg maturation in the ovaries. Taking Clomiphene in the beginning of the menstrual cycle ensures regulation of ovulation, especially in women with defective ovulation and through it improves the chances of pregnancy.
Letrozole is a non-steroidal aromatase inhibitor that decreases the estrogen levels produced by the female body to aid in reproduction. Patients using Letrozole towards the end of their menstrual cycle for 5 days have recorded successful results in around 19% of cases.
HCG or Follicle Stimulating Hormone
Follicle Stimulating Hormones also referred to as Gonadotropins are the treatment options when Clomiphene does not yield satisfactory results. They are usually used as a part of assisted reproductive technology to stimulate follicle growth alongside intravaginal ultrasound. The aim of ultrasound is to monitor the size of eggs growing inside the follicles due to the HCG injections.
Bromocriptine or Cabergoline
Bromocriptine is a dopamine agonist, while Cabergoline is a dopaminergic substance used to inhibit the production of prolactin in the human body. Prolactin levels can be increased due to hormonal changes, use of certain medications and sometimes systemic conditions. These can interfere with menstrual cycles and ovulation and affect the patients’ reproductive health. Studies have shown that 90% of women have normal prolactin levels, and 85% ovulate successfully.
Hysteroscopy and Laparoscopy are two surgical methods used when medications fail in producing results. Hysteroscopy involves the surgeon using a small lighted tube or hysteroscopy to check for blockages or abnormal growths. The identified growths, e.g. fibroids and polyps, are then surgically removed in the same sitting. Laparoscopy uses a camera and other operative instruments for more detailed evaluation. In this method, the surgeon makes a tiny incision in the abdomen to insert the camera. Both of these methods are performed under general anaesthesia and treat a variety of conditions like Endometriosis, Fallopian tube blockage, pelvic adhesions with help in egg retrieval for assisted reproductive technologies.
Assisted Reproductive Technologies
Assisted Reproductive Technologies follow a combination of medications and hormonal therapy to aid in successful reproduction. These are combined with procedures like in vitro fertilization or IVF, intrauterine insemination or IUI and zygote intrafallopian transfer or ZIFT to strengthen the success rates of fertilization.
Intrauterine insemination or IUI is used in cases of low sperm count, decreased sperm motility, mild endometriosis and in cases of male partners having issues with ejaculation or erection. It uses the technique of concentrated sperm transfer to the uterus through an injection method. It is less invasive and cheaper than other assisted reproduction techniques. But it has a variable success rate depending on the age, the severity of the problem and response to the treatment by the patient.
Gamete Intrafallopian Transfer (GIFT)
In this method, multiple eggs are collected from the ovaries and placed in a catheter with the sperm. Through the laparoscopy method, the mixture is injected into the fallopian tubes for assisted fertilization.
In vitro Fertilization (IVF)
In vitro Fertilization involves retrieving eggs from a woman’s ovaries and fertilizing them with sperm. Depending on the situation, your eggs are fused with your partner’s or donor sperm. Sometimes donated eggs and embryos are also used as per the condition of the female and treatment plan of the surgeon. The embryo once obtained can be frozen for storage, transferred into the patient’s uterus or implanted in a surrogate or gestational carrier. IVF has the highest success rate of all procedures with the success rate in females below 35 years of almost 43%.
Zygote Intrafallopian Transfer (ZIFT)
Zygote Intrafallopian transfer combines IVF and Gamete Intrafallopian transfer for achieving positive pregnancy outcome. In this method, eggs are stimulated and collected using IVF methods and fused with sperm through laboratory methods. The fertilized eggs are laparoscopically returned to the fallopian tubes to be implanted in the uterus and converted to a fetus.
Which is the Best Option?
Currently IVF is the best option for achieving successful outcomes. It provides successful outcomes in women with blocked fallopian tubes through using their own eggs. It gives good outcomes to older women above the age of 40 trying to conceive. It addresses male infertility problems by using a donor sperm or using the Intra Cytoplasmic Sperm Injection techniques. IVF has proved especially beneficial in patients with PCOS who do not conceive with ovulation induction. Cases of unexplained infertility, endometriosis and premature ovarian failure have been seen to respond better to IVF than other methods. Most importantly, it is safe and since its inception has been further refined for the benefit of the patients.
Is Prevention Better than Cure?
While surgeries, medications and assisted technologies are extremely helpful in providing successful outcomes, there are certain risk factors that, on being addressed at the right time, can put a check on the problem. Age, lifestyle factors, weight and sexual history though minor factors play an important role in the problem especially when combined together. Maintaining a healthy weight through regular exercising and diet changes, avoiding smoking and alcohol and being careful about your sexual history can go a long way in taking care of the problem. Most importantly, reducing stress and getting timely help for your condition can do what all the medications or other treatments failed to do and improve your success rates of reproduction to a vast extent.