Fertility is defined as probability of achieving a pregnancy within two years of unprotected sex. Infertility is not a disease but a symptom which more than physical causes mental agony.
Fertility can be impaired due to problems encountered in either or both partners. Male and female factors contribute to 30-35% of infertility, while l0% belongs to the unexplained group. Unexplained infertility means that all the known investigations performed on both the partners are normal and the cause of infertility is unknown. 20-25% of infertility is due to varied combination of problems.
When diagnosing and treating infertility the woman's age is very much a cause of concern to the clinician. In these times with women sacrificing their prime years to profession and career their fertility is taking a backseat. This is so because with increasing age both the number and the quality of eggs deteriorate.
There is no evidence whatsoever to state a drop in male fertility with age. However there is concern regarding the spermatozoa being affected by the varied pollutants around us. Thus increasing levels of pollution especially in the metros is an area of concern. There remains no doubt that male infertility is also on a rise.
1. Causes of Infertility in Female
Ovulation problems:Involve conditions which prevent the release of a mature egg from the ovary. Commonly this may due to hormonal imbalances called Polycystic Ovarian Syndrome. Here the ovary contains small cysts and do not mature and release an egg regularly.
Endometriosis: Is a condition in which uterine lining which sheds with each menstrual period grows outside the uterus and causes infertility.
Female tube blockages:Sexually transmitted diseases, previous tubal sterilization surgery or repeated infection of pelvis, previous abortions and deliveries can block the tubes.
Uterine factors: fibroids, polyp, septum, synechia can prevent gamete transport, embryo implantation to the uterus leading to infertility.
Cervical Factors: Tight cervix, chronically infected cervix,scarred cervix due to surgeries though rare can lead to infertility .
Poor Egg Quality: Eggs that become damaged or develop chromosomal abnormality, which is usually an age related problem significantly in late 30's and early 40's.
Poor Sperm Quality any one or all or combination of count, motility and/or morphology can cause infertility
Anatomical obstructions in the sperm transport tubes, varicocoeles (varicose veins of testis), and sexually transmitted diseases blocking tubes.
Immunological: seen in l0% of patients which causes them to produce antibodies that kill the sperm.
This term is used where the cause of infertility cannot be identified. In these cases all the available investigations reveal no known cause which could be attributed as the cause of infertility.
Couples who have both male and female infertility problems.
Polycystic Ovarian Syndrome: (PCOS)
This is a hormonal disorder with wide ranging effects not only on fertility but also on the patients’ general health. 30-40% of infertile patients are PCOS. Women with PCOS may menstruate (and ovulate) irregularly or may not menstruate (ovulate) at all. Hormonal imbalance leading to anovulation (no ovulation) is the primary cause. There is also resistance to insulin utilization by the body. This leads to increase in androgen (which is a male hormone) which prevents eggs from maturing and releasing (ovulating).
PCOS is thought to be a familial disease (genetical inheritance). These patients have a higher risk of cardiac disease, hypertension and endometrial cancer in future.
Common symptoms include
1. Menstrual disturbance: irregular, infrequent or absent menstrual periods
2. Obesity
3. Male patter of balding.
4. Male patter of sexual hair (moustache, beard, navel, chest, thighs, pubic hair).
5. Acne.
6. acanthosis migracaus (soft dark thick skin in back of neck, groin and armpit).
Investigations required for diagnosis of this condition are
1. Fasting blood sugar for glucose intolerance,
2. Hormone levels
3. ultrasound of ovaries
4. Insulin assays.
Pretreatment is aimed at correcting this hormonal imbalance.
- Metformin (oral diabetic medicine) helps in overcoming insulin resistance and decreasing the androgen levels.
- Tablets like clomiphene, injections like gonadotrophins (FSH, HMG) stimulate ovulation.
- Weight reduction, anti androgen drugs help in reducing male hormones.
- As a last resort laparoscopic ovarian drilling wherein 8 -10 holes are made using electric current will reduce male hormones.
Once pregnant these patients are at a high risk of a miscarriage and hence metformin is continued till completion of first 3 months of pregnancy. Additional medicines (progesterone support, etc) are also prescribed. They are also at risk of pregnancy induced diabetes mellitus.
Recurrent Pregnancy Loss:
Definition: Three or more consecutive (in a row) pregnancy losses that occur prior to fetal viability (usually 20 week’s gestation or a fetal weight of 500 grams).
The reason for this criteria is the reports of a significantly higher chance for further pregnancy loss following the loss of "three in a row."
The two major clinically important categories of causes for spontaneous abortion (miscarriage) are fetal and maternal.
Laparoscopy / Keyhole surgery
Laparoscopy forms the cornerstone for surgical evaluation of pelvis after basic tests being completed. More so in cases where endometriosis or pelvic inflammatory disease (PID) is suspected. It is a procedure done under General anaesthesia in a Operation Theatre. A small needle is inserted into abdominal cavity through the navel and then Co2 gas is introduced into the abdominal cavity. A Laparoscope (a telescope with strong light and camera) is then introduced, through a puncture wound at the navel. A variety of instruments can also be passed through accessory punctures.These can be used to perform corrective surgery.
The following organs/diseases can be examined through the laproscope
- Uterus and its abnormalities like fibroids.
- Tubes and ovaries.
- Endometriosis
- Adhesions or bands between uterus, tube and ovaries and other organs.
- Inspection of appendix, intestine, upper abdominal organ
Advantages of laparoscopic surgery are
1.Incisions are very small hence recovery is faster and discomfort is minimal.
2.Chances of further adhesions are less.
3.Decreases hospital stay and cost effective.
Other operative procedures which can be done through laproscopy are
- Problems like opening blocked tubes,
- removing cysts from the ovaries
- or fibroids from uterus,
- clearing endometriosis
- removing tubal pregnancy,
- recanalising tubes after tubal sterilization.
These are tumors which arise from the muscle tissue of uterus and may grow into the,
- cavity of uterus (submucous fibroids),
- or grow within the uterine wall (intramural),
- or protrude outside the uterus (subserous).
Symptoms: Submocous fibroid causes abnormal heavy bleeding, anaemia, pain, infertility or miscarriage. Other types like subserous or intramural fibroids cause pressure on bladder, rectum, and lower abdominal pain. Fibroids may cause infertility, recurrent pregnancy loss and premature delivery. Miscarriage rates are as high as 40% in presence of large fibroids.
Any fibroid greater than 3cm should be removed. Submucous fibroids of any size or the ones obstructing the fallopian tubes should be removed.
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