Infertility

What is Infertility?

Definitions of Infertility

  • Inability to conceive at the intended time: Refers to the couple's failure to achieve pregnancy despite engaging in regular unprotected sexual intercourse.

  • Duration of Unprotected Regular Sexual Activity: Defined as a duration of 1 year of unprotected, regular sexual activity that does not result in conception.

  • Repeated Pregnancy Wastage: This refers to recurrent spontaneous abortions (miscarriages) occurring after confirmed pregnancies.

Types of Infertility

  • Primary Infertility: Refers to couples who have never achieved pregnancy.

  • Secondary Infertility: Refers to couples who have previously conceived but are unable to achieve subsequent pregnancies.

Incidence of Infertility

  • Time Frame: Analyzed data from 2015-2019.

  • Target Group: Women ages 15-44 who are married or cohabiting.

  • Infertility Rate: 7.6% of this group experienced infertility.

  • Impaired Fecundity: 12.7% experienced impaired fecundity, which is the reduced ability to conceive.

  • Historical Comparison: Rates were stable—infertility was 6.6% in 2011-2015, and impaired fecundity was 12.1%.

Perceptions of Infertility

  • Increased Perception of Infertility: Rising perceptions are attributed to:

    • Decreased Birth Rates: Families are having fewer children.

    • Decreased Fertility Rates: There is a perception that the ability to conceive has been declining.

Contributing Factors to Infertility

Factors in Men

  • Abnormalities of the Sperm:

    • Oligospermia: Characterized by a low number of sperm in the semen, affecting fertility.

  • Abnormal Erections: Impeding the potential for vaginal intercourse.

  • Abnormal Ejaculation:

    • Conditions include slow, absent, retrograde, or premature ejaculation.

    • Retrograde Ejaculation: Semen is discharged into the bladder rather than out of the urethra.

    • Erectile Dysfunction: The inability to achieve or maintain an erection sufficient for penetration.

  • Abnormalities of the Seminal Fluid: The quality of the fluid can negatively impact fertility.

  • Impaired Sperm Production: This can occur due to genetic factors, hormonal imbalances, or environmental factors that affect the testes' ability to produce sperm.

Factors in Women

  • Disorders of Ovulation: Conditions that disrupt the normal ovulation cycle can impact fertility.

  • Abnormalities of the Fallopian Tubes:

    • Endometriosis: A condition where tissue similar to the uterine lining grows outside the uterus, potentially blocking the tubes.

  • Cervical Abnormalities: Conditions affecting the cervix can obstruct sperm travel.

  • Repeated Pregnancy Loss: Involves multiple miscarriages that complicate future pregnancy efforts.

Diagnostic Tests for Infertility

For Males

  • Semen Analysis: Evaluates the function and structure of sperm.

  • Endocrine Testing: Assesses the hypothalamus, pituitary gland, and testicular response.

  • Ultrasonography: Used to evaluate the structural aspects of the male reproductive system.

  • Testicular Biopsy: Allows for identification of pathologies leading to infertility.

  • Sperm Penetration Assay: Tests the ability of sperm to penetrate egg barriers.

For Females

  • Ovulation Prediction: Various methods are used to confirm ovulation timing.

  • Ultrasonography: Evaluates the structure of the female reproductive organs.

  • Hysterosalpingogram: Assesses whether the uterine cavity and the fallopian tubes are open and functioning.

  • Postcoital Test: Analyzes the presence and viability of cervical mucus as it relates to sperm motility.

  • Hormonal Assessments: Measure hormone levels such as luteinizing hormone (LH) and progesterone to confirm ovulation and evaluate overall reproductive health.

Interventions: Medications for Infertility

  • Medications can serve to improve fertility prospects for both males and females.

  • Medications for Males:

    • Erectile Agents: Improve erectile function.

    • Hormonal Treatments: Includes LH recombinant DNA origin, Gonadotropins, GnRH antagonists, Bromocriptine, Cabergoline.

  • Medications for Females:

    • Metformin: Commonly used for women with polycystic ovary syndrome.

    • Progesterone: Plays a key role in the menstrual cycle and early pregnancy.

    • Clomiphene Citrate: Used to induce ovulation.

  • Common Treatments for Both Genders:

    • FSH recombinant DNA origin: Stimulates ovarian activity.

    • GnRH agonists: Control hormone release.

    • Chorionic Gonadotropin: Includes for ovulation induction.

    • Clomiphene Citrate: Promotes ovulation by blocking estrogen receptors.

Surgical Interventions for Infertility

For Males

  • Varicoceles: The most common cause of male infertility.

  • Microsurgery: Address issues including structural malformations and blockages.

    • Varicocelectomy: Involves ligating or embolizing dilated veins.

    • Vasovasostomy: Surgical rejoining of the vas deferens.

    • Success Rate: 87% of men regain fertility post-surgery.

  • Sperm Extraction Techniques:

    • Open Surgery: Utilizes a microscope for sperm retrieval from testicular tissue tubules.

  • For Females:

  • Minimally Invasive Surgeries:

    • Laparoscopy and Hysteroscopy: Precision surgical techniques to address infertility factors.

    • Procedures may include laser surgery for fibroids, polyps, and adhesions.

  • Laparotomy: Involves larger incisions to correct pelvic adhesions from endometriosis or infections.

  • Transcervical Balloon Tuboplasty: Unblocks fallopian tubes using balloon catheters through the cervix.

Interventions: Sperm Donation

Purpose of Sperm Donation

  • Utilized in cases of:

    • Low sperm count.

    • Male fertility defects or disorders.

    • A female desiring a future child without a male partner.

Screening Process for Donors

  • Health history and family health background.

  • Blood type and Rh factor assessment.

  • Genetic screenings for disorders such as Sickle Cell Anemia and Tay-Sachs Disease.

  • Screening for STIs, including HIV.

  • Semen is frozen for a duration of 6 months before use.

Collection and Processing of Donation

  • Collection typically occurs via masturbation.

  • The process involves washing to eliminate factors like prostaglandins and antibodies for purity prior to concentration and insemination.

Risks of Sperm Donation

  • Inadvertent Consanguinity: Risk where children born from the same donor may unknowingly intermarry.

Interventions: Egg Donation

  • Purpose: Egg donation is an alternative for women who cannot produce healthy eggs necessary for conception.

  • Donor Selection: Typically, younger, fertile women are preferred, as they often lead to higher IVF success rates.

  • Donation Limitations: To prevent inadvertent consanguinity, egg donors are restricted to a specific number of donations.

Donor Screening Process

  • Documentation: FDA medical history questionnaire, physical exams for health assessments, and infectious disease evaluations.

  • Genetic Screening: Necessary to rule out congenital conditions.

  • Psychological Counseling: Ensures the emotional readiness for donation.

Risks Involved in Egg Donation

  • Ovarian Hyperstimulation Syndrome (OHSS): A significant risk associated with medications that stimulate the ovaries.

  • Possible side effects include bleeding, cramping, and infection.

In Vitro Fertilization (IVF)

Process Overview

  1. Follicle Maturation: Medication is used to stimulate ovarian follicles to mature eggs.

  2. Ovum Retrieval: Eggs are collected via transvaginal or laparoscopic methods.

  3. Fertilization: Eggs are fertilized using microscopy, monitoring cell division for a 5-day duration.

  4. Implantation: Fertilized eggs are implanted directly into the uterus, bypassing the fallopian tubes to enhance implantation likelihood.

    • The success rate of pregnancy is approximately 18%.

Gamete Intrafallopian Transfer (GIFT)

Procedure Overview

  • Eligibility: Women must have at least one open or patent fallopian tube.

  1. The procedure resembles IVF, involving the retrieval of eggs and processing of sperm.

  2. The mixture of sperm and eggs is introduced into each fallopian tube using a catheter via a laparoscope.

  3. Additional prepared sperm may also be placed in the uterus through the cervix to enhance the chances of fertilization.

  4. Post-Procedure: Progesterone is administered to support uterine preparation.

  • GIFT may be seen as an ethically acceptable alternative by some religious groups. This procedure can provide an opportunity for couples facing infertility by allowing them to use their own gametes in a less invasive manner compared to traditional IVF methods.

Zygote Intrafallopian Transfer (ZIFT)

Procedure Overview

  • Definition: A hybrid procedure merging aspects of IVF and GIFT.

  1. Fertilization follows the same process as IVF.

  2. Hormone therapy is provided to encourage successful implantation.

  3. The zygote is then implanted into a patent fallopian tube, with one remaining unobstructed.

  4. Risks: Ectopic pregnancy is a potential complication; positive fertilization evidence may provide reassurance to the couple. However, close monitoring is essential to detect any abnormalities early on and to ensure the health of both the mother and the developing embryo. In some cases, multiple gestations may occur, increasing the risk of premature labor and necessitating more intensive prenatal care.