What is Infertility?
Infertility is “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse .
Most couples (approximately 85%) will achieve pregnancy within one year of trying, with the greatest likelihood of conception occurring during the earlier months. Only an additional 7% of couples will conceive in the second year.
Infertility may be caused by many factors including problems with egg or sperm production, genetic factors, age, or too much exposure to certain chemicals and toxins.
Causes of Infertility?
Anti-Mullerian Hormone (AMH) is a hormone secreted by cells in developing egg sacs (follicles). The level of AMH in a woman’s blood is generally a good indicator of her ovarian reserve.
AMH is produced solely in the granulosae cells of pre antral and antral ovarian follicles. Measuring the AMH levels gives an indication of the size of the cohort.
The number of antral follicles (the cohort) size, correlates with fertility potential. Young women, who normally have better fertility, will normally have a larger number of antral follicles visible on ultrasound and higher AMH levels.
Low anti-Mullerian hormone and high follicle stimulating hormone levels are indicators of diminished ovarian reserve (DOR), a decline in the ovaries’ ability to produce good-quality eggs. DOR is one of the major causes of infertility among women. In reverse, high AMHcan signal polycystic ovary syndrome (PCOS)
The level of AMH in the blood can help to estimate the number of follicles inside the ovaries, and therefore, the woman’s egg count. A typical AMH level for a fertile woman is 1.0–4.0 ng/ml; under 1.0 ng/ml is considered low and indicative of a diminished ovarian reserve.
The study found women with high AMH levels were 2.5 times more likely to have a successful IVF cycle than women of a similar age with low levels of the hormone. … “High levels of this hormone mean there is a greater chance they have plenty of healthy eggs remaining to support a pregnancy.”
Women with PCOS have higher level of AMH, and therefore have high number of small (antral and preantral ) follicles and at risk of developing OHSS with hormonal stimulation.
What is Endometriosis ? What are the types of endometriosis?
Endometriosis is a disorder in which tissue similar to the tissue that forms the lining of uterus grows outside of uterine cavity. The lining of uterus is called the endometrium. Endometriosis occurs when endometrial tissue grows on ovaries, bowel, and tissues lining pelvis.
Endometriosis is classified into one of four stages (I-minimal, II-mild, III- moderate, and IV-severe) based upon the exact location, extent, and depth of the endometriosis implants as well as the presence and severity of scar tissue and the presence and size of endometrial implants in the ovaries.
Endometriosis and Infertility
Endometriosis is a very common debilitating disease that occurs in 6 to 10% of the general female population; in women with pain, infertility, or both, the frequency is 35–50%. About 25 to 50% of infertile women have endometriosis, and 30 to 50% of women with endometriosis are infertile.
Should I get preganant with endometriosis?
Yes definitely. Grade 1 and 2 which may cause low ovarian reserve needs Ovulation Induction, 3-4 IUI can be done depending upon patient’s age. Grade 3 and 4 level needs surgical management with IVF to get pregnant.
POOR OVARIAN RESERVE
Ability of the ovaries to generate viable eggs from the earliest follicles in the ovaries is called ovarian reserve.
Poor ovarian reserve is a condition of low fertility characterized by 1): low numbers of remaining oocytes in the ovaries or 2) possibly impaired preantral oocyte development or recruitment.
Known causes of diminished ovarian reserve include smoking, endometriosis, previous ovarian surgery, exposure to toxic chemicals, chemotherapy or radiation. In many cases, the cause is unknown and most likely reflects a combination of environmental and genetic causes.
Tests to detect ovarian reserve
There are many tests but commonly used are transvaginal sonography done in early days of menustrual cycle day 2-5 to detect no. small follicles measuring 2-5 mm and serum level of AMH.
No treatment can stop the process of diminished ovarian reserve, but women who are infertile due to low egg count or quality can sometimes use IVF to achieve a pregnancy.
Fallopian tube obstruction is a major cause of female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm to meet, thus making fertilization impossible.
Approximately 20% of female infertility can be attributed to tubal causes.
There are three types of tubal blockages
1. Proximal tubal occlusion: This form of fallopian tube blockage involves the isthmus
2.Mid-segment tubal obstruction: It occurs in the ampullary section of the fallopian tube and is most frequently a result of tubal ligation damage.
3. Distal tubal occlusion: This is a kind of blockage wherein the section of the fallopian tube that is close to the ovary is affected and is commonly associated with a condition known as hydrosalpinx
Causes of Tubal Block
- Pelvic inflammatory disease. This disease can cause scarring or hydrosalpinx.
- Tuberculosis very common cause in India for tubal damage.
- Endometrial tissue can build up in the fallopian tubes and cause a blockage.
- Certain sexually transmitted infections (STIs).
- Past ectopic pregnancy.
- Past abdominal surgery.
Blocked tubes are usually diagnosed with a specialized x-ray called a hysterosalpingogram or HSG. This test involves placing a dye through the cervix using a tiny tube. Once the dye has been given, the doctor will take x-rays of your pelvic area.
If fallopian tubes are blocked by small amounts of scar tissue or adhesions, doctor can use laparoscopic surgery to remove the blockage and open the tubes. If fallopian tubes are blocked by large amounts of scar tissue or adhesions, treatment to remove the blockages may not be possible.
For PID and Tuberculosis medical + surgical correction required
The most common treatment for women with hydrosalpinx is surgery whereas the affected or blocked tube gets removed. This surgery is known as salpingectomy. Surgery can also be an option to remove scar tissue or other adhesions that could negatively affect fertility.
Blocked fallopian tubes prevent natural conception, but in vitro fertilization (IVF) can bypass the tubes and achieve the Fertility.
If Hydrosalphinx is there on laparoscopy or it is seen in sonography it needs removal or clipping of the fallopian tube because fluid trickling from hydrosalphinx into uterine cavity will reduce the success rate of IVF by 50%.
Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods.
Fibroids affect around 30 percent of all women by the age of 35 years, and from 20 to 80 percent by the age of 50 years.
They usually develop between the ages of 16 to 50 years. These are the reproductive years during which estrogen levels are higher.
The type of fibroid a woman develops depends on its location in or on the uterus.
Intramural fibroids are the most common type of fibroid. These types appear within the muscular wall of the uterus. Intramural fibroids may grow larger and can stretch your womb.
Subserosal fibroids form on the outside of your uterus, which is called the serosa. They may grow large enough to make your womb appear bigger on one side.
Subserosal tumors can develop a stem, a slender base that supports the tumor. When they do, they’re known as pedunculated fibroids.
These types of tumors develop in the middle muscle layer, or myometrium, of your uterus. Submucosal tumors aren’t as common as the other types.
Estrogen and progesterone are the hormones produced by the ovaries. They cause the uterine lining to regenerate during each menstrual cycle and may stimulate the growth of fibroids.
It is only submucosal fibroids which protrude into the uterus that may affect fertility.
There are several ways uterine fibroids can reduce fertility: Changes in the shape of the cervix can affect the number of sperm that can enter the uterus. Changes in the shape of the uterus can interfere with the movement of the sperm or embryo. Fallopian tubes can be blocked by fibroids
Fibroids can also cause problems during pregnancy as well. These include:
- Placental abruption – detachment of the placenta, causing bleeding and loss of pregnancy.
- Abnormal growth of the pregnancy – occurring from fibroids affecting blood flow or the size of the fibroids, preventing the baby from growing properly.
- Pre-term labor and birth – preventing normal growth leading to contractions and early labor. Early labor may lead to an early delivery of the baby and possible developmental problems.
Medications for uterine fibroids target hormones that regulate menstrual cycle. It helps in treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids, but may shrink them. Medications include:
- Gonadotropin-releasing hormone (GnRH) agonists
- Progestin-releasing intrauterine device (IUD)
- Tranexamic acid (Lysteda, Cyklokapron)
- Selective progesterone receptor modulator(Ulipristal)
- Abdominal myomectomy. If there are multiple fibroids, very large fibroids or very deep fibroids, doctor may use an open abdominal surgical procedure to remove the fibroids.
A uterine malformation is a type of female genital malformation resulting from an abnormal development of the Müllerian duct(s) during embryogenesis. Symptoms range from amenorrhea, infertility, recurrent pregnancy loss, and pain, to normal functioning depending on the nature of the defect.
The types of congenital uterine anomalies include:
Septate: a normal external uterine surface but two endometrial cavities.
Bicornuate: an abnormal, indented external uterine surface and two endometrial cavities.
Arcuate: a normal external uterine surface with a 1 cm or less indentation into the endometrial cavity.
Didelphys : the uterus is present as a paired organ
Bicornis biocolis : a uterus that is more or less completely divided into two
Unicorns : has a single horn linked to the ipsilateral fallopian tube that faces its ovary.
Multiple imaging modalities exist to diagnose the presence of uterine anomalies. These include 2-dimensional (2D) ultrasound, 3D transvaginal ultrasound, saline infusion sonohysterography (SIS), hysterosalpingography (HSG), diagnostic hysteroscopy, and magnetic resonance imaging (MRI).
Many women with uterine anomalies do not require treatment. If pain, miscarriage, or infertility is an issue recommend correcting the anomaly surgically. Most cases of uterine anomalies can be corrected through minimally invasive techniques, such as laparoscopy or hysteroscopy.
Male infertility refers to a male’s inability to cause pregnancy in a fertile female. In humans it accounts for 40–50% of infertility. It affects approximately 7% of all men. Male infertility is commonly due to deficiencies in the semen, and semen quality
SIGNS AND SYMPTOMS ASSOCIATED WITH MALE INFERTILITY INCLUDE:
- Problems with sexual function — for example, difficulty with ejaculation or small volumes of fluid ejaculated, reduced sexual desire, or difficulty maintaining an erection (erectile dysfunction)
- Pain, swelling or a lump in the testicle area
- Recurrent respiratory infections
- Inability to smell
- Abnormal breast growth (gynecomastia)
- Decreased facial or body hair or other signs of a chromosomal or hormonal abnormality
- A lower than normal sperm count (fewer than 15 million sperm per milliliter of semen or a total sperm count of less than 39 million per ejaculate)
Problems with male fertility can be caused by a number of health issues and medical treatments. Some of these include:
- A varicocele is a swelling of the veins that drain the testicle. It’s the most common reversible cause of male infertility. Although the exact reason that varicoceles cause infertility is unknown, it may be related to abnormal testicular temperature regulation. Varicoceles result in reduced quality of the sperm.
Treating the varicocele can improve sperm numbers and function, and may potentially improve outcomes when using assisted reproductive techniques such as in vitro fertilization.
- Some infections can interfere with sperm production or sperm health or can cause scarring that blocks the passage of sperm. These include inflammation of the epididymis (epididymitis) or testicles (orchitis) and some sexually transmitted infections, including gonorrhea or HIV. Although some infections can result in permanent testicular damage, most often sperm can still be retrieved.
Ejaculation issues :
Retrograde ejaculation occurs when semen enters the bladder during orgasm instead of emerging out the tip of the penis. Various health conditions can cause retrograde ejaculation, including diabetes, spinal injuries, medications, and surgery of the bladder, prostate or urethra.
Some men with spinal cord injuries or certain diseases can’t ejaculate semen, even though they still produce sperm. Often in these cases sperm can still be retrieved for use in assisted reproductive techniques.
Antibodies that attack sperm
Anti-sperm antibodies are immune system cells that mistakenly identify sperm as harmful invaders and attempt to eliminate them.
- Cancers and nonmalignant tumors can affect the male reproductive organs directly, through the glands that release hormones related to reproduction, such as the pituitary gland, or through unknown causes. In some cases, surgery, radiation or chemotherapy to treat tumors can affect male fertility.
In some males, during fetal development one or both testicles fail to descend from the abdomen into the sac that normally contains the testicles (scrotum). Decreased fertility is more likely in men who have had this condition.
Infertility can result from disorders of the testicles themselves or an abnormality affecting other hormonal systems including the hypothalamus, pituitary, thyroid and adrenal glands. Low testosterone (male hypogonadism) and other hormonal problems have a number of possible underlying causes.
Defects of tubules that transport sperm
Many different tubes carry sperm. They can be blocked due to various causes, including inadvertent injury from surgery, prior infections, trauma or abnormal development, such as with cystic fibrosis or similar inherited conditions. Blockage can occur at any level, including within the testicle, in the tubes that drain the testicle, in the epididymis, in the vas deferens, near the ejaculatory ducts or in the urethra.
Inherited disorders such as Klinefelter’s syndrome — in which a male is born with two X chromosomes and one Y chromosome (instead of one X and one Y) — cause abnormal development of the male reproductive organs. Other genetic syndromes associated with infertility include cystic fibrosis, Kallmann’s syndrome and Kartagener’s syndrome.
Problems with sexual intercourse
These can include trouble keeping or maintaining an erection sufficient for sex (erectile dysfunction), premature ejaculation, painful intercourse, anatomical abnormalities such as having a urethral opening beneath the penis (hypospadias), or psychological or relationship problems that interfere with sex.
A digestive disorder caused by sensitivity to gluten, celiac disease can cause male infertility. Fertility may improve after adopting a gluten-free diet.
Testosterone replacement therapy, long-term anabolic steroid use, cancer medications (chemotherapy), certain antifungal medications, some ulcer drugs and certain other medications can impair sperm production and decrease male fertility.
Certain surgeries may prevent you from having sperm in your ejaculate, including vasectomy, inguinal hernia repairs, scrotal or testicular surgeries, prostate surgeries, and large abdominal surgeries performed for testicular and rectal cancers, among others. In most cases, surgery can be performed to either reverse these blockage or to retrieve sperm directly from the epididymis and testicles.
Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm production or sperm function. Specific causes include:
Extended exposure to benzenes, toluene, xylene, pesticides, herbicides, organic solvents, painting materials and lead may contribute to low sperm counts.
Heavy metal exposure
Exposure to lead or other heavy metals also may cause infertility.
Radiation or X-rays
Exposure to radiation can reduce sperm production, though it will often eventually return to normal. With high doses of radiation, sperm production can be permanently reduced.
Overheating the testicles
Elevated temperatures impair sperm production and function. Although studies are limited and are inconclusive, frequent use of saunas or hot tubs may temporarily impair your sperm count. Sitting for long periods, wearing tight clothing or working on a laptop computer for long stretches of time also may increase the temperature in your scrotum and may slightly reduce sperm production.
Health, lifestyle and other causes
Some other causes of male infertility include:
Anabolic steroids taken to stimulate muscle strength and growth can cause the testicles to shrink and sperm production to decrease. Use of cocaine or marijuana may temporarily reduce the number and quality of your sperm as well.
Drinking alcohol can lower testosterone levels, cause erectile dysfunction and decrease sperm production. Liver disease caused by excessive drinking also may lead to fertility problems.
Men who smoke may have a lower sperm count than do those who don’t smoke. Secondhand smoke also may affect male fertility.
Stress can interfere with certain hormones needed to produce sperm. Severe or prolonged emotional stress, including problems with fertility, can affect your sperm count.
- Research shows that the likelihood of pregnancy may be lower if a male partner has severe depression. In addition, depression in men may cause sexual dysfunction due to reduced libido, erectile dysfunction, or delayed or inhibited ejaculation.
- Obesity can impair fertility in several ways, including directly impacting sperm themselves as well as by causing hormone changes that reduce male fertility.
Certain occupations including welding or those involving prolonged sitting, such as truck driving, may be associated with a risk of infertility. However, the research to support these links is mixed.
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