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Infertility

Definition


Disease: Infertility Infertility
Category: Sexual diseases

Disease Definition:

When a couple is unable to get pregnant despite having frequent, unprotected sex for at least a year, it means that they are infertile. If this is the case with a couple, there might be a chance that something treatable may be interfering with their efforts to have a child. The cause behind infertility may be a single problem in the patient or the partner, or a mix of factors that interfere with the occurrence or continuity of pregnancy. Infertility may luckily be treated by safe and effective therapies. There may be a greater likelihood of pregnancy with these treatments.
 

Work Group:


Symptoms, Causes

Symptoms:

Almost 85% of couples become pregnant if not within the first six months, probably after 12 months of unprotected intercourse. Over the next 36 months, about half of the remaining couples will be conceiving without help. The inability of a couple to become pregnant is an indication to infertility. This condition may not cause any other apparent symptoms.

 

While some signs of hormonal problems may be apparent in an infertile man such as changes in sexual function or in hair growth, an infertile woman may go through abnormal menstrual periods. A person should not be generally worried about infertility before regularly trying to conceive for at least one year, but a doctor may be consulted earlier in case:

 

  • The woman has a history of irregular or painful menstrual cycles, pelvic pain, pelvic inflammatory disease (PID), repeated miscarriages or endometriosis
  • The man that has low sperm count or a history of testicular, sexual or prostate problems
  • The woman is older than 30 or hasn’t menstruated in six months.
     

Causes:

When the intricate processes of ovulation and fertilization start working right, the couple become pregnant, since the human reproductive process is complex: 

 

  • Each month a signal is sent by the pituitary gland in a woman’s brain to her ovaries in order to prepare an egg for ovulation.
  • Ovulation is the condition of ovaries being stimulated by the pituitary hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) to release an egg. This is when a woman is fertile (often about day 14 of a 28- day menstrual cycle).
  • After the egg is released, it travels through the fallopian tube and is able to be fertilized within about 24 hours. When intercourse happens one or two days before the ovulation, conception may occur.
  • The sperm must unite with the egg in the fallopian tube during this time in order for pregnancy to occur. In order to achieve conception, the sperm and the egg must be present in the fallopian tube simultaneously, because sperm are able to fertilize the egg for up to 72 hours. When the man has an erection and ejaculates enough semen to deliver the sperm into the vagina then the sperm will be able to reach an egg, but there must be sufficient sperm, and it must be the right shape and move in the right path. Additionally, the woman must have a healthy vaginal and uterine environment to enable the sperm to travel to the egg.
  • When the egg is fertilized, it moves into the uterus where it attaches to the uterine lining and starts a nine-month process of growth.

 

A problem might come up for certain couples who are attempting pregnancy along this complex process causing infertility. The reason or reasons underlying infertility can involve one or both partners:

 

  • In about 20% of cases, infertility is the result of a cause involving only the male partner.
  • In about 30 to 40% of cases, the reason behind infertility involves both male and female.
  • In the remaining 40 to 50% of cases, infertility is due entirely to the female partner.

 

CAUSES OF MALE INFERTILITY:

Impaired ability to fertilize the egg, impaired sperm count or mobility may result from several things. Abnormal sperm production or function, general health and lifestyle issues, overexposure to some environmental elements and impaired delivery of sperm are the most common reasons underlying male infertility.

 

Impaired production or function of sperm:

The following are problems with the sperm that most infertile males  encounter:

 

Impaired shape and movement of sperm: 

In case the shape and structure (morphology) of the sperm are abnormal or the movement (motility) is impaired, sperm may not be capable of reaching or penetrating the egg. It must be properly shaped and able to move in a quick and accurate way toward the egg so that fertilization may occur.

 

Low sperm concentration: 

When a sperm contains 10 million or fewer sperm per milliliter of semen, it means the man has low sperm concentration (subferitility), and if it is 40 million sperm or over per milliliter of semen this means the man has increased fertility, for a normal sperm concentration is either greater than or equal to 20 million sperm per milliliter of semen. Total failure of the testicles to produce sperm rarely occurs.

 

Varicocele:

This condition is a varicose vein in the scrotum that may inhibit normal cooling of the testicle, contributing to decreased sperm count and motility.

 

Undescended testicle:

If one or both testicles fail to descend from the abdomen into the scrotum at the time of fetal growth, this condition occurs. Sperm production may be affected due to the testicles being exposed to the higher internal body temperature, compared with the temperature in the scrotum.

 

Testosterone deficiency (male hypogonadism): 

An abnormality affecting the hypothalamus or pituitary gland in the brain producing the hormones that manage the testicles or disorders of the testicles themselves may be able to cause infertility in a man.

 

Genetic defects:

Abnormal development of the testicles may result from a genetic defect called Klinefelter’s syndrome, a condition in which a man has two X chromosomes and one Y chromosome instead of one X and one Y. This condition causes low or absent sperm production and maybe low testosterone.

 

Infections: 

Male infertility is most frequently related to repeated bouts of sexually transmitted diseases (STDs) as is the case with Chlamydia and gonorrhea. Infection may affect sperm motility for a short period of time. These infections can block sperm passage and result in scarring. Additionally, sperm motility may also be altered due to inflammation of the prostate (prostatitis), epididymis or urethra. When a male is affected with mumps after puberty, a viral infection which often affects young children, inflammation of the testicles can impair sperm production.

 

Decreased sperm production is not always explainable. Genetic testing can reveal if there are subtle changes in the Y chromosome for genetic causes could be involved when sperm concentration is less than 5 million per milliliter of semen.

 

Impaired delivery of sperm

Infertility may be the outcome of problems in delivering the sperm from the penis into the vagina, such as:

 

Retrograde ejaculation: 

Several conditions can result in retrograde ejaculation such as prostate, bladder or urethral surgery; the use of some medications; and diabetes. This condition occurs when instead of emerging out through the penis during an orgasm, the semen enters the bladder.

 

Sexual issues: 

Fertility may be affected by problems with sexual intercourse or technique, though this is usually a treatable problem. Infertility may result from premature ejaculation, painful intercourse (dyspareunia), erectile dysfunction, or relationship or psychological problems. Fertility may also be impaired in the case of using lubricants like petroleum jelly or oils, because they can be toxic to the sperm.

 

No semen (ejaculate): 

Men who have spinal cord injuries or diseases may suffer from the absence of ejaculate. This is the fluid that carries sperm from the penis into the vagina.

 

Blockage of epididymis or ejaculatory ducts: 

While some men lack the tube carrying sperm (vas deferens) from the testicle out to the opening in the penis, others may be born with blockage of the part of the testicle containing sperm or ejaculatory ducts (epididymis).

 

Anti-sperm antibodies: 

After surgical blockage of part of the vas deferens for male sterilization (vasectomy), antibodies often target sperm and either weaken or disable them. The reversal of a vasectomy may become complicated due to the presence of these antibodies.

 

Misplaced urinary opening (hypospadias): 

A birth defect can result in the urinary (urethral) opening to be abnormally positioned on the underside of the penis. This condition can keep sperm from reaching the woman’s cervix unless it is surgically corrected.

 

Cystic fibrosis: 

Men usually have a missing or obstructed vas deferens in case they suffer from cystic fibrosis.

 

General health and lifestyle:

A man’s fertility may be affected by his general health and lifestyle. The following are common reasons underlying infertility related to health and lifestyle:

 

Emotional stress:

Stress may occur when a problem with fertility itself occasionally becomes prolonged and discouraging. A man’s sperm count may be affected in case he has been going through emotional stress for a long period of time, because stress may interfere with some hormones that are required to produce sperm.

 

Obesity:

High body mass may be related to fertility problems in men.

 

Malnutrition:

Infertility may result from deficiencies in nutrients like zinc, folate, vitamin C and selenium.

 

Cancer and its treatment:

Fertility may be affected in males due to the removal of one or both testicles because of cancer. Sperm production can be impaired and occasionally severely by both radiation and chemotherapy treatment. There’s even a greater risk of infertility if the radiation treatment is closer to the testicles.

 

Alcohol and drugs:

Infertility can result from certain drug use. As is the case when a man is addicted to alcohol or drug that can lead to decreased fertility and poor health. For instance, anabolic steroids that are taken to stimulate muscle strength and growth can cause the testicles to shrink and in turn reduce sperm production.

 

Other medical conditions:

Male fertility can be affected by a major surgery or a severe injury. Infertility may be related to several diseases or conditions like thyroid disease, Cushing’s syndrome, diabetes or anemia.

 

Age:

There’s more likelihood for men who are older than 40 to be less fertile when compared to younger men.

 

Environmental exposure:

Sperm count may be decreased either directly by affecting testicular function or indirectly by altering the male hormone system when being overexposed to certain environmental elements like chemicals, toxins and heat. The following are specific underlying reasons:

 

Pesticides and other chemicals:

Exposure to lead can cause infertility in men. Both insecticides and herbicides may result in female hormone-like effects in the male body that may be related to decreased sperm production and testicular cancer.

 

Overheating the testicles:

When a man uses saunas or hot tubs often, his core body temperature elevates which may lead to impairment of sperm production and lower sperm count.

 

Substance abuse:

The number and quality of the sperm may be decreased for a short period of time with the use of cocaine or marijuana.

 

Tobacco smoking:

Men who smoke are more likely to have a lower sperm count when compared to those who don’t.

 

CAUSES OF FEMALE FERTILITY:

Polycystic ovary syndrome (PCOS), benign uterine fibroids, pelvic adhesions, fallopian tube damage or blockage, early menopause, ovulation disorders and high prolactin are among the most common reasons underlying female infertility.

 

Fallopian tube damage or blockage:

Chlamydia, a sexually transmitted disease that results in the inflammation of the fallopian tube (salpingitis) is the most frequent reason behind fallopian tube damage. This kind of damage may either result in pain and fever or it may go unnoticed. Tubal damage may cause a pregnancy in which the fertilized egg is not capable of reaching through the fallopian tube in order to implant in the uterus (ectopic pregnancy). One episode of tubal infection may result in fertility difficulties. Each time a tubal infection occurs, the risk of ectopic pregnancy goes higher.

 

Endometriosis:

Women with this condition may typically have pelvic pain and infertility. As the uterine tissue implants and grows outside of the uterus, this condition occurs, usually interfering with the way ovaries, fallopian tubes and uterus work. Scarring and inflammation may result when the above mentioned implants react to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month.

 

Ovulation disorders:

Disruption in the part of the brain that regulates ovulation can result in low levels of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Ovulation disorders may result in infertility in some women. Even slight irregularities in the hormone system can keep the ovaries from releasing eggs (anovulation). Tumors, extra exercise, injury and starvation are among specific reasons underlying hypothalamic pituitary disorders causing anovulation. Certain medications can also be related to ovulation disorders.

 

Elevated prolactin (hyperprolactinemia):

Prolactin is the hormone responsible for stimulation of breast milk production.  Ovulation may be affected when a woman who isn’t pregnant or nursing has too much prolactin in her. An elevation in prolactin levels may additionally point out to the existence of a pituitary tumor. Certain drugs can also elevate levels of prolactin. Milk flow not associated with either nursing or pregnancy can be a sign of increased prolactin.

 

Polycystic ovary syndrome (PCOS):

The body in PCOS produces too much of the hormone androgen, affecting ovulation. This condition is additionally related to insulin resistance and obesity.

 

Early menopause (premature ovarian failure):

Some conditions are known to be related to early menopause, even though the exact cause is unknown, such as smoking, radiation or chemotherapy or immune system diseases. Early menopause is the absence of menstruation and the early depletion of ovarian follicles preceding the age of 40.

 

Uterine fibroids:

These are benign tumors in the wall of the uterus and are common in women who are in their 30s and 40s. They may rarely result in infertility by blocking the fallopian tubes. More frequently, fibroids interfere with proper implantation of the fertilized egg.

 

Pelvic adhesions:

These adhesions are bands of scar tissue binding organs after pelvic infection; abdominal or pelvic surgery; or appendicitis. Fertility may be impaired due to this scar tissue formation.

 

Other causes in women:

Medications:

Infertility may occur for a short period of time due to the use of certain medications. Though mostly, fertility is restored as soon as the woman quits the medication.

 

Thyroid problems:

The menstrual cycle can be interrupted by the disorders of the thyroid gland, either too little thyroid hormone (hypothyroidism) or too much (hyperthyroidism) resulting in infertility.

 

Cancer and its treatment:

Chemotherapy may impair reproductive function and fertility in both men and women. Some cancers, especially female reproductive cancers, usually severely impair female fertility. A woman may not be able to reproduce due to both chemotherapy and radiation.

 

Other medical conditions:

Women’s fertility may be impaired due to medical conditions related to late puberty or amenorrhea, as is the case in Cushing’s disease, kidney disease, diabetes and sickle cell disease.

 

Caffeine intake:

Fertility in women may be decreased due to extra caffeine consumption.

 

The following are risk factors leading to infertility in both men and women:

 

Age:

A woman’s fertility potential slowly declines after around the age of 32, infertility in older women may be because of an elevated rate of chromosomal abnormalities that take place in the eggs as they age. Additionally, older women are also more likely to have health problems that may interfere with fertility. There’s a great risk of miscarriage related to a woman’s age. Men over the age of 40 for instance, may be less fertile when compared to younger men.

 

Tobacco smoking:

Miscarriages are seen more often in women who smoke. Tobacco smokers both men and women may decrease their chances of achieving a pregnancy and decrease the possible benefit of fertility treatment.

 

Alcohol use:

There is no safe level of alcohol use for women during conception or pregnancy. However, male fertility doesn’t seem to be reduced by moderate alcohol use.

 

Being overweight:

A man’s sperm count may be affected in case he is overweight. A sedentary lifestyle seems to be the cause of being overweight in women, which also causes infertility.

 

Being underweight:

Women who have eating disorders like bulimia or anorexia nervosa may be included among the risk group as well as those who are following a very low calorie or restrictive diet. Additionally, strict vegetarians may go through infertility problems because of the lack of important nutrients like folic acid, zinc, iron and vitamin B-12.

 

Too much exercise:

Ovulation problems have been linked in certain studies to exercising more than seven hours a week. On the other hand though, exercise that isn’t sufficient can lead to obesity, raising the risk of infertility as well.

 

Caffeine intake:

There are mixed study results about whether consuming too much caffeine may be related to decreased fertility. Certain studies have pointed to a reduction in fertility with high caffeine use while others have not shown adverse effects. In case effects exist, it’s more likely that it’ll be greater on the woman’s fertility than the man’s. High caffeine intake does seem to be raising the risk of miscarriage.

Complications

Complications:

None

Treatments:

Taking into consideration the reason underlying infertility, how long the person has been infertile, the age of the partners and several personal preferences, treatment may be determined. Certain causes of infertility cannot be corrected. Yet, a woman may still be able to become pregnant with assisted reproductive technology or other operations to restore fertility.

 

TREATMENT FOR COUPLES

The following approaches can contain steps associated with the male or female partner, or both. Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation. Having intercourse two to three times a week may improve fertility, so increasing the frequency of intercourse may be of great help. But too-frequent ejaculation can lessen quality of the sperm.

 

TREATMENTS FOR MEN:

The following are treatment approaches that involve the male partner:

 

General sexual problems:

Fertility may be improved by addressing either impotence or premature ejaculation. Medication or behavioral approaches often treat these problems.

 

Lack of sperm:

When there’s a doubt about lack of sperm as being the reason behind a man’s infertility, surgery or hormones correcting the problem or use of assisted reproductive technology can occasionally be a possibility. For instance, varicocele can usually be surgically corrected. Sperm can either be taken directly from the testicles or recovered from the bladder and injected into an egg in a laboratory setting in both cases of retrograde ejaculation and blockage of the ejaculatory duct.

 

TREATMENT FOR WOMEN:

Fertility drugs that trigger ovulation are generally similar to natural hormones, like luteinizing hormone (LH) and follicle-stimulating hormone (FSH). The main treatment for women who are infertile because of ovulation disorders are fertility drugs that either regulate or induce ovulation. The following are fertility drugs that are commonly used in such cases:

 

Clomiphene:

This drug makes the pituitary gland release more FSH and LH in order to stimulate the growth of an ovarian follicle that has an egg. Women suffering from polycystic ovary syndrome (PCOS) or other ovulatory disorders take this medication orally to stimulate ovulation.

 

Human menopausal gonadotropin (hMG):

Women who are incapable of ovulating on their own because of the failure of their pituitary gland to stimulate ovulation take an injection of this medication. This medication contains both LH and FSH and like other gonadotropins, it directly stimulates the ovaries, not like clomiphene that stimulates the pituitary gland instead.

 

Follicle-stimulating hormone (FSH):

FSH works by stimulating the ovaries to mature egg follicles.

 

Human chorionic gonadotropin (HCG):

This medication stimulates the follicle to release its egg (ovulate) and is used in combination with clomiphene, FSH and hMG.

 

Gonadotropin-releasing hormone (Gn-RH) analogs:

Gn-RH analogs deliver constant Gn-RH to the pituitary gland, altering hormone production in order to enable the doctor to induce follicle growth with FSH. This treatment is recommended for women who either ovulate prematurely before the lead follicle is sufficiently mature, during hMG treatment or for those who have irregular ovulatory cycles.

 

Aromatase inhibitors:

This class of medications is approved for treatment of advanced breast cancer, and includes anastrozole and letrozole. Letrozole, which is not approved by the FDA for inducing ovulation, may occasionally be prescribed for women who are unable to ovulate on their own and who haven’t benefitted from treatment with clomiphene citrate. The drug’s manufacturer has warned doctors not to use the drug for fertility purposes due to the possibility of adverse health effects, such as miscarriage and birth defects.

 

Metformin:

When there’s a suspicion of insulin resistance to be causing infertility, this medication is prescribed to be taken orally in order to boost ovulation. Insulin resistance may play a role in the development of PCOS.

 

Bromocriptine:

When high levels of the hormone stimulating milk production in new mothers (prolactin) causes irregularities in a woman’s ovulation cycles, bromocriptine is prescribed in order to inhibit the production of prolactin.

 

FERTILITY DRUGS AND THE RISK OF MULTIPLE PREGNANCIES:

There’s a high chance of multiple births due to oral fertility drugs like clomiphene, although in much lower rate when compared to injectable fertility drugs. The use of these medications needs careful monitoring by using blood tests, ultrasound measurement of ovarian follicle size and hormone tests. In general, the greater the number of fetuses, the higher the risk of premature labor. Premature babies are at a high risk of health and growth problems. These risks are higher for triplets than for twins or single pregnancies.
In case a woman needs an HCG injection to trigger ovulation and ultrasound exams indicate there being several follicles developed, both the doctor and woman may decide to withhold the HCG injection. This way, the risk of multiple pregnancies can be decreased. Yet, for many couples, the desire to become pregnant overrides worries about having multiple babies.

 

For several people, serious emotional and ethical challenges may be the issue when one or more fetuses are removed (multifetal pregnancy reduction) providing improved survival odds for the surviving fetuses when there are too many babies conceived. When a couple has fertility drug treatment in mind, before starting treatment they should talk about it with their doctor.

 

SURGERY:

Surgery may be a treatment option for infertility, based on the reason behind its occurrence. Blockages or other problems in the fallopian tubes can usually be surgically repaired. Delicate operations may be allowed to be performed on the fallopian tubes with laparoscopic methods.

 

Though hormones like the ones available in birth control pills work best in relieving pain and treating endometriosis, but they haven’t been beneficial in treating infertility. This is why it is usually difficult to treat infertility that resultes from endometriosis. Ovulation therapy may be recommended to treat endometriosis, in which case a medication either stimulates or regulates ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.

 

ASSISTED REPRODUCTIVE TECHNOLOGY (ART):

ART has revolutionized the treatment of infertility. The most common forms of ART include:

 

In vitro fertilization (IVF):

This method is the best working ART method. Retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization is involved in the IVF technique. If both fallopian tubes are blocked, IVF is usually recommended. Additionally, it’s widely used for several other conditions like unexplained infertility, male factor infertility, ovulation disorders, endometriosis and cervical factor infertility. IVF needs frequent blood tests and daily hormone injections as well. IVF raises the chances of having more than one baby at a time due to multiple fertilized eggs that are usually implanted into the uterus so that there is a greater chance that one will develop into a baby.

 

Electric or vibratory stimulation to achieve ejaculation:

Electric or vibratory stimulation brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who are otherwise unable to achieve ejaculation.

 

Surgical sperm aspiration:

Surgical sperm aspiration involves removing sperm from part of the male reproductive tract, like the epididymis, testicle or vas deferens. In case the ejaculatory duct is blocked, this method allows retrieval of sperm.

 

Intracytoplasmic sperm injection (ICSI):

This technique consists of a microscopic method (micromanipulation), in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. This method has been particularly helpful in couples who have failed once before to achieve conception with standard methods. ICSI raises the chance of improving fertilization for men suffering from low sperm concentrations.

 

Assisted hatching:

This method attempts to assist the implantation of the embryo into the lining of the uterus.

 

There’s a lower rate of success for ART after the age of 35. If the woman has a healthy uterus, ovulates naturally, uses donor eggs or reacts well to fertility drugs, there’s a greater chance for ART to be beneficial. Either donor sperm should be present or the man should have healthy sperm.

 

COMPLICATIONS OF TREATMENTS:

Treating infertility may result in complications, such as:

 

Multiple pregnancies:

Multiple pregnancies are considered to be the most typical complication of ART. The couple decides about the number of quality embryos kept and matured to fetuses and birth ultimately. In case there are too many babies conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.

 

Ovarian hyperstimulation syndrome (OHSS):

The woman’s ovaries may enlarge and result in pain and bloating in the case of overstimulation. When this condition isn’t promptly treated, mild to moderate symptoms may usually resolve, even though pregnancy may delay her recovery. Fluid accumulates depleting blood volume and lowering blood pressure in the abdominal cavity and chest, though rare, resulting in abdominal swelling and shortness of breath. There’s a higher risk of developing OHSS in younger women and those who have polycystic ovary syndrome in comparison with other women.

 

Bleeding or infection:

There is a risk of bleeding or infection with assisted reproductive method as is the case with any invasive procedure.

 

Low birth weight:

Multiple pregnancies is the greatest risk factor for low birth weight. There may be a greater chance of low birth weight related to ART in single live births.

 

Birth defects:

ART is the most successful fertility-enhancing therapy to date. There are certain worries about the possible relationship between ART and birth defects. In order to confirm this possible connection, more research is required. In case a couple is considering whether to take advantage of this treatment or not, they should weigh the above mentioned factors.
 

Prognosis:

Not available

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