INFERTILITY

                                                                       

                                   

   
  This is defined as a couple’s inability to achieve pregnancy after 1 year of unprotected intercourse. Primary infertility refers to a couple who has never had a child. Secondary infertility means that at least one conception has occuerred, but currently the couple cannot achieve a pregnancy. In the United States, infertility affects 6 million couples. It is often a complex physical problem, and its causes are usually related to azoospermia, anovulation, or tubal obstruction.

      Most infertility is really some degree of subfertility and 1 in 7 couples who have conceived before. The WHO (1992) defines subfertility as ‘the inability of a couple to achieve conception or to bring a pregnancy to term after a year or more of regular, unprotected intercourse’. 

     Infertility is categorized as primary if there has been no prior conception and secondary if there has been a previous pregnancy irrespective of the outcome. Couples now have fewer than two children on average in most European countries and they tend to postpone reduction in fertility. Under normal circumstances the chance of a couple conceiving within one menstrual cycle is 20-25% given that unprotected intercourse occurs at the optimum time, the female partner is ovulating regularly and the male partner is producing sperm of sufficient quality. Approximately one-third of  cases of infertility involve problems with both partners in one-third of couples the causes of infertility remain unexplained. The most common causes are ovulation failure and sperm disorders.

INITIAL MANAGEMENT OF THE INFERTILE COUPLE

     Much of the initial management is via primary care, therefore the preliminary investigation of both partners and subsequent  referral to specialist care will be through the general practitioner. Each referral should be instigated for couples where the female partner is over 35 years and where there is amenorrhoea or significant pelvic infection.

                                 CAUSES OF INFERTILITY

MALE INFERTILITY

ENDOCRINE DISORDERS

Dysfunction of

·        Hypothalamus

·        Pituitary

·        Adrenals

·        Thyroid

Systemic disease

·        Diabetes mellitus

·        Coelic disease

·        Renal failure

Testicular disorders

·        Trauma

·        Environmental (high temperature)

Congenital ( hydrocele, undescended testes)

Occupational (furnaceman, long distance lorry driver)

Acquired ( Varicocele, tight clothing)

·        Cancer treatment

Defective transport

·        Obstruction or absence of seminal ducts:

·        Infection

·        Congenital anomalies

·        Trauma

Impaired secretions from prostate or seminal vesicles:

·        Infection

·        Metabolic disorders

Ineffective delivery

·        Psychosexual problems (impotence)

·        Drug-induced (ejaculatory dysfunction)

·        Physical disability

·        Physical anomalies

Hypospadias

Epispadias

Retrograde ejaculation (into bladder)

FEMALE INFERTILITY

Defective ovulation

Endocrine disorders

Dysfunction of

·        Hypothalamus

·        Pituitary

·        Adrenals

·        Thyroid

Systemic disease

·        Diabetes mellitus

·        Coelic disease

·        Renal failure

Physical disorders

·        Obesity

·        Anorexia nervous or strict dieting

·        Excessive exercise

Ovarian disorders

·        Hormonal

·        Ovarian cysts or tumours

·        Polycystics ovary disease

·        Ovarian endometiosis

Defective transport

·        Ovum

·        Tubal obstruction

Infection (gonorrhea, peritonitis, pelvic inflammatory disease)

Previous tubal surgery

·        Fimbrial adhesians

·        Previous surgery

·        Endometriosis

Sperm

Vaginal

·        Psychosexual problems (Vaginismus)

·        Infection (causing dyspareunia)

·        Congenital anomaly

Cervix

·        Cervical trauma  or surgery (cone biopsy)

·        Infection

·        Hormonal (hostile mucus)

·        Antisperm antibodies in mucus

Defective implantation

·        Hormonal imbalance

·        Congenital anomalies

·        Fibroids

·        Infection

ASSISTED REPRODUCTIVE TECHNIQUES

     A range of assisted reproductive techniques is available to treat the infertile couple and it is important that the appropriate treatment option is offered. Those techniques include the followings:

·        In vitro fertilization (IVF) treatment

·        Donor insemination (DI) treatment

·        Gamete intrafallopian transfer (GIFT) where donated sperm or eggs are used in treatment.

·        Storage of gametes or embryos

Each of the techniques highlighted above will be discussed in details in the next article.

OVULATION INDUCTION

     There are many reasons for ovulatory failure and although menstruation is strongly suggestive of ovulation it is not conclusive. Women with amenorrhoea or oliogomenorrhoea can be treated with ovulation inducing agents provided that the male partner has an adequate sperm count.

Clomifene is the most commonly prescribed drug but should be prescribed only when there are no other factors contributing to infertility and there is access to ovarian ultrasound feedback that stimulates the release of GnRH; which in turn leads to an increase in FSH and ovarian follicular growth and can be effective in up to 80% of appropriately selected women.

     Treatment should be limited to six cycles with the lowest effective dose. The side effect of clomifene include multiple pregnancy and ovarian hyperstimulation and minority of women may experience symptoms such as hot flashes, abdominal distention, nausea, vomiting, breast tenderness, headaches, hair loss and blurred vision.

     Women with clomifene  resistant polycystic ovarian syndrome (PCOS) can be treated with human menopausal gonadotrophin (HMG) and FSH injections. Cabergoline as  opposed to bromocriptine, is rapidly becoming the treatment of choice for women suffering from anovulatory hyperprolactinaemia. This is because latter is associated with the unpleasant side effects of nausea, headaches, vertigo and drowsiness whereas the former has significantly fewer side effects.

INTRAUTERINE INSEMINATION (IUI)

IUI is indicated where there are problems such as hostile cervical mucus, antisperm antibodies or male fertility problems such as low sperm count, premature ejaculation, retrograde ejaculation, anatomical problems or impotence. It is also useful for cases of unexplained infertility. The tubal patency of the female partner must be assured.  In order to increase the chances of success, ovulation is induced and the sperm prepared to maximize its fertilizing ability before being inserted high into the uterus.