Infertility

Who is at fault?

The female partner is responsible for infertility in 40% of cases and the male in another 40%. In a few of the cases both are at fault. However, in 20% cases no cause can be found.

What are the causes of infertility in women?

• The ovaries do not produce eggs, or these may be defective.
  
• The fallopian tubes or the tubes that transfer the egg from the ovary to the uterus may be blocked or non-functional. This may happen in cases of infections like tuberculosis, endometriosis, or previous surgery of tubes or ovaries.
  
• The uterus and cervix normally produce a thin discharge. If this mucous is excessively thick or contains substances that kill the sperms, then this prevents sperms from swimming through it into the uterine cavity and then to the tubes.
  
• Distorted or partially blocked uterine cavity as in fibroids.

What are the causes of infertility in males?

• Men normally produce at least 20 million sperm per ml of semen. If the sperm count is less than this it may adversely affect fertility.
  
• Of the sperms present in the semen, 50% must be actively moving sperms for conception to occur. A lower percentage of actively moving sperms will be unable to swim through the cervix to meet the egg in the fallopian tube.
  
• If more than 50% sperms are abnormal in shape and function, this can also lead to infertility.
  
• If the testes do not produce sperms or these are unable to come out due to blockage of the vas deferens, the tube which carries the sperms from testis out.
  
• Inability to perform normal intercourse due to difficulties in ejaculation, impotence or structural abnormalities of the penis.

How can the woman know her time of ovulation?

Ovulation is the time when the ovaries produce an egg that enters the fallopian tube. Just before ovulation, the mucous discharge from the vagina increases. In addition, there may be lower abdominal discomfort or pain for a period ranging from half an hour to 24 hours.

If one maintains a basal body temperature chart by taking a daily morning temperature, a rise in temperature by 0.5 degree centigrade around the thirteenth or fourteenth day indicates ovulation. Urine testing kits are also available which help in identifying the time of ovulation by showing a surge of a hormone which is associated with ovulation .

What tests are done for women?

The doctor first takes a detailed clinical history to ascertain the possible cause of infertility. If the problem lies in faulty sexual practice, this can be easily corrected. Structural abnormalities in the sex organs are looked for, and sometimes an ultrasound scan may need to be done. Blood and urine tests may be done to look for infection. A laparoscopy can also be performed for diagnosis, in which a telescope in inserted into the abdomen to visualise the internal organs including the uterus , ovaries and tubes.

The potency of the fallopian tubes is tested by performing a hysterosalpingography or HSG. In this a dye is injected into the uterus and X-rays are take which show the filling up of the tubes. No anaesthesia is required for this test and there is only minimal discomfort.

What tests are done for men?

Men are advised to undergo an analysis of their semen. For this, the semen is collected by masturbation. The man must have abstained from sexual intercourse for 3 to 5 days before giving the semen sample for testing. In semen analysis the sperm count is done and the structure and motility of sperms is assessed. If there is a doubt about the functional status of the testes, a biopsy is taken from the testes, usually under local anaesthesia for testing.

What is the management of infertility?

This depends on the cause of infertility. Every case may need a different approach depending on the nature of the problem and the underlying defect.

• Problems with ovulation: If there is a problem with ovulation, certain drugs need to be given to induce ovulation or correct it.
  
• Fallopian tube block: This is treated surgically by a laparoscope or by an open microsurgery technique. In this the blocked segment is excluded and continuity of the patent tubes is re-established. This is a technically demanding procedure. In cases were tubes cannot be corrected by this method, or the procedure fails assisted reproductive procedures (ART) such as in-vitro fertilization (IVF) is undertaken.
  
• Cervical Factor: If the problem lies in the cervix, this can be overcome with procedures such as intrauterine insemination (in which the semen is injected into the uterine cavity) or procedures such as IVF or GIFT (Gamete Intra-Fallopian Transfer ).

Problems in men: Minor problems will respond to medical treatment or to surgery. Intrauterine insemination can help in some of the cases. However, if the problem is not corrected by the above measures then assisted conception by IVF can be offered with considerable success. In cases with very severe sperm deficiency, until a few years ago, the treatment of couple had not been very successful. Micro-manipulation now can be offered to these couples.