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Fertility problems and its causes

The inability to conceive comes as a surprise to most men and women, all of whom assume that pregnancy will immediately follow marriage or after a contraceptive method is discontinued.However, that is not the case with approximately 10% to 15% of couples.

Couples who have difficulty to conceive may experience frustration, jealousy, guilt and anger.However, once they begin to explore the medical options, they find that recent advances in medication, microsurgery, and in vitro fertilization (IVF) techniques offer more hope for a successful pregnancy than ever before. Pregnancy is now possible for most of the couples pursuing treatment.

Sometimes what prevents the pregnancy is easy to treat, but in some cases factors that prevent pregnancy are difficult to identify, or treat. The decision to seek treatment for infertility is a viable one thanks to the ART. You and your spouse should not delay seeking professional help. If there’s a specific problem causing infertility, the sooner you begin therapy, the closer you are to achieving your goal. Our doctors will give you a reasonable idea of your chances of achieving pregnancy. The choice of which treatment to pursue appropriate to your circumstances will be recommended by your fertility specialist and you can influence your choice. It’s important to remember that you are in control of the treatment.

The likelihood of achieving a natural pregnancy for a fertile couple is about 20% per each month. With the use of medications to correct ovulatory disorders, intrauterine insemination (IUI) and IVF procedures (collectively referred to as assisted reproduction technology (ART), and surgery to correct anatomical problems, certain infertile couples have a chance of pregnancy similar to that of a fertile couple or even higher. Given that over 50% of our patients get pregnant with their first trial, some may need to consider retrying. It’s up to you how many times you are willing to try. With patience, a positive attitude and the appropriate treatment, many infertile couples can eventually have their target achieved.

Different IVF procedures in our centre have resulted in a pregnancy rate in the range of 45% to 60% per egg retrieval. In some cases, success may require repeated attempts before conception may occur. However, this is true even in couples who do not experience fertility problems.


Cause of the infertility: The Male Factor
In approximately 40% of infertile couples, the husband is either the sole or a contributing cause of infertility. Therefore, a semen analysis is very important. The man is usually asked to abstain from ejaculating for at least 48 hours although that is not mandatory in all cases. He will then produce a semen sample by masturbating into a clean labelled plastic specimen pot provided in a private room at our centre or at home. In some instances, a semen sample may be obtained during sexual intercourse using a special silicone condom that does not contain substances that kill sperm. Sometimes two semen analyses are recommended, since sperm quality can vary over time.

Cause of the infertility: The Ovulation disorders
The menstrual cycle may reveal some important clues about ovulation. Irregular or abnormal ovulation is found in approximately 40% of all infertility cases. Tests for detecting ovulation include charting the basal body temperature (BBT), monitoring the cervical mucus status and change, using over the counter ovulation prediction kits, serial ultrasound examination, and measuring the blood progesterone level. This blood test is performed on day 19 to day 23 of a 28-day menstrual cycle. An adequately elevated progesterone level confirms ovulation.

Cause of the infertility: The Tubal Factor
Open, healthy fallopian tubes are necessary for conception. Therefore, tests to determine tubal patency (openness) are important. When a hysterosalpingogram (HSG) – an x-ray procedure with an injection of dye into the uterus through the cervix – shows blocked tubes, a diagnostic laparoscopy to determine the cause and the extent of the tubes’ damage may be necessary. Laparoscopy is an important part of a thorough infertility investigation and should not be unnecessarily delayed, especially in older patients, in those with abnormal HSG findings, and if no pregnancy occurs within 6 to 12 months of treatment in the presence of a normal x-ray. If the tubes are found to be blocked, scarred or damaged, laparoscopic surgery can sometimes correct the problem or enhance the chance of the pregnancy either by dividing adhesions, or restoring patency. If, however, the tubes are badly damaged their removal may improve pregnancy prospects.

Cause of the infertility: The Uterine Factor
Ultrasound examination and a hysterosalpingogram (HSG) may reveal defects inside the uterus or fallopian tubes. An HSG is conducted after the menstrual period stops and before ovulation. Polyps and an abnormally shaped uterine cavity are found in about 5% of infertile women. Fibroids (benign growth of the muscle of the uterus) are found in about 40% of the women (the majority of whom get pregnant without difficulty). Large fibroids, which distort the fallopian tubes and bulge inside the uterine cavity, affect the chance of the pregnancy. Uterine polyps, fibroids and uterine anomalies can interfere with the implantation of the early embryo or increase the incidence of a miscarriage. Hysteroscopy may be recommended to further evaluate or treat abnormalities detected via HSG and surgery may be required to further evaluate and possibly correct uterine structural problems.

Hysteroscopy is a telescopic examination that allows the inside of the uterus to be inspected under direct vision. It can be performed under local sedation or general anaesthesia. It is a day case operation, which is particularly appropriate for the detection and correcting of any uterine abnormalities such as polyps, adhesions, septum and in particular, treating submucous fibroids.

Cause of the infertility: The Cervical Factor
At mid-cycle, the cervical mucus should be clear, colourless, watery, abundant and stretchable. When these conditions are present, sperm can easily pass up into the uterus and fallopian tubes. If the mucus quality is poor or inadequate, the cervix may not be functioning properly. It is rarely the sole cause of delays in becoming pregnant.

Cause of the infertility: The Peritoneal Factor
The peritoneum is a covering layer of pelvic organs.Adhesions, endometriosis or pelvic infection are the major causes of abnormal peritoneal function. In the majority of these cases, laparoscopy is the only means of diagnosis and in some cases the conditions for pregnancy may be improved by dividing the adhesions.

Laparoscopy
Laparoscopy is performed under general anaesthesia, usually as a day case. During the procedure, a fibre optic telescope called a laparoscope is inserted through a small incision (less than 1 cm) within or just below the navel. We then look directly into the abdominal cavity and the pelvis is inspected, including the ovaries, tubes, uterus and peritoneum. A dye is usually injected through the cervix to determine if the passage to the uterus and tubes is open. One or more additional small incisions may also be made to better aid the handling and inspection of the pelvic organs.

Cause of the infertility: Unexplained Infertility
In approximately 10% of couples seeking pregnancy, all tests are normal; and in a much higher percentage of couples, only minor abnormalities are found.

Fertility treatment should achieve a higher pregnancy rate than just waiting for spontaneous pregnancy (with no medication) to occur. Studies showed that spontaneous pregnancy occurs in about 10-15% of couples with unexplained infertility. Doctors use different kind of treatment to increase the chance of pregnancy in this group of patients. Fertility medication (tablets to increase FSH secretion and FSH injections) and/or natural cycle intrauterine insemination (IUI) have been used to empirically treat unexplained infertility with limited success (pregnancy rate close to that achieved by waiting for spontaneous pregnancy). A combination of gonadotropins (FSH injections) and IUI may achieve a higher chance of pregnancy than just waiting for the spontaneous pregnancy.

An increased age of the women, four unsuccessful IUI treatments, or longstanding duration of infertility justify further endoscopic (laparoscopy and hysteroscopy) examination as well as a quick resort to IVF.  

 

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Wassel Sotak

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