December 6, 2016

Infertility

Reproductive health refers to the normal function and dysfunction of the male and female reproductive systems throughout the life course. Disorders of reproduction include infertility and reduced fertility. Other disorders include birth defects, developmental disorders, low birth weight, preterm birth, impotence, and menstrual disorders. There is a body of research that has made a strong link between exposure to environmental pollutants and the threat to reproductive health. One such pollutant is heavy metals and lead is associated with reduced fertility in both men and women. Another is mercury which when an individual is exposed to this heavy metal it could lead to birth defects and neurological disorders. A growing body of evidence suggests that exposure to endocrine disruptors, chemicals that appear to disrupt hormonal activity in humans and animals, may contribute to problems with fertility, pregnancy, and other aspects of reproduction.

Fertility

Fertility is the natural capability to produce offspring and it is controlled by hormones. Having intercourse as close as possible to ovulation definitely helps.

What is Infertility?

Infertility is a fairly common reproductive health disorder in approximately 15% of couples. What infertility means is the inability of a couple to become pregnant after a year of trying. Infertility can be traced to the woman in a third of the cases. Another third of cases is attributed to infertility in the male. The remainder of cases is because both partners have infertility issues or no cause can be found. If a woman can get pregnant but keeps having miscarriages or stillbirths, that’s also called infertility.

Fertility treatments are specific for men or for women. Some involve both partners. Surgery, drugs and assisted reproductive technology are common treatment options to resolve infertility. The success rate of fertility treatment is very encouraging as many couples go on to have babies.

What are the common causes of infertility?

All of the steps during ovulation and fertilization need to happen correctly in order for the woman to get pregnant. Sometimes the issues that cause infertility in couples are present at birth or they develop later in life.

Causes of male infertility

These may include:

  • Abnormal production of sperm due to
    • undescended testicles,
    • genetic defects,
    • health problems such as diabetes or
    • infections such as chlamydia, gonorrhea, mumps or HIV.
    • Enlarged veins in the testes (varicocele) can also affect the quality of sperm.
  • Issues with the delivery of sperm are due to sexual problems such as:
  • premature ejaculation
  • cystic fibrosis and other genetic disorders
  • structural problems, such as a blockage in the testicle; or damage or injury to the reproductive organs.
  • Environmental factors include:
  • overexposure to chemical including pesticides
  • Medical therapy related to cancer and its treatment, including radiation or chemotherapy can damage the reproductive organs and impair sperm production.

Other factors which cause infertility

It has been established that nicotine, alcohol, marijuana and some prescription drugs such as antibiotics, anti-hypertensives, steroids (anabolic) or others, can also affect fertility in some individuals. Prolonged heat exposure in some occupations as well as recreational exposure to heat in saunas or hot tubs may affect sperm production.

Causes of female infertility may include:

  • Ovulation disorders

Ovulation is the monthly release of a mature egg from one of the two ovaries. This process can be disrupted by hormonal disorders such as polycystic ovary syndrome, hyperprolactinemia, hyperthyroidism or hypothyroidism. Excessive exercise and eating disorders can also interfere with ovulation. Both conditions are seen in female athlete triad syndrome. Physical trauma or tumors of the ovaries will impact ovulation.

  • Anatomical abnormalities of the uterine or cervical

Abnormalities of the cervix, uterus include congenital abnormalities, tumors (including fibroids) and cancers. These can interfere with implantation of the fertilized egg.

  • Damaged or blocked fallopian tubes

Sexually transmitted infections can lead to pelvic inflammatory disease which could lead to blocked fallopian tubes.

  • Endometriosis

Endometrial tissue which grows outside of the uterus is called endometriosis. It may be found on the ovaries, uterus and fallopian tubes. Endometrial tissue outside of the uterus responds to the menstrual hormonal changes and often bleed during menstruation.

  • Early menopause

Early menopause occurs before age 40. Medical conditions which can induce this are immune system diseases, certain genetic conditions such as Turner syndrome. Smoking, radiation or chemotherapy treatment can induce early menopause.

  • Pelvic adhesions: bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery.

 

Risk factor for both male and female infertility are the same. They include:

  • Age

Fertility gradually declines with age for both males and females. For the woman the decline begins in her mid-30s due to the decrease in the number and quality of eggs. With respect to men he becomes less fertile over the age of 40.

  • Tobacco use

Smoking of both tobacco and marijuana by either partner reduces the likelihood of pregnancy. Smoking also impairs fertility treatment. Women who smoke are more likely to have miscarriages. Erectile dysfunction and a low sperm count in men are more frequently seen in men who smoke.

  • Alcohol use

Alcohol use increases the risk of birth defects, and may contribute to infertility. Heavy alcohol use in males can decrease sperm count and motility.

  • Overweight and obesity

Being overweight may increase the risk of infertility in both males and females. For overweight males sperm count may also be affected.

  • Being underweight

Women at risk of fertility problems include those with eating disorders, including anorexia or bulimia. A very low calorie or restrictive diet may also contribute to infertility issues.

  • Exercise issues

Insufficient exercise and a sedentary lifestyle contribute to obesity, which may in turn increase the risk of infertility. Female athletes who engage in intense, strenuous exercise can develop ovulatory issues.

Diagnosis

Infertility evaluation can be expensive, and sometimes involves invasive procedures. Unfortunately there is no guarantee fertility testing and counseling will result in a successful pregnancy.

Tests for men

Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the woman’s vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including examination of your genitals. Specific fertility tests may include:

  • Semen analysis: Semen is usually obtained by masturbating or by interrupting intercourse and ejaculating your semen into a lab specimen container. A lab analyzes your semen specimen.
  • Hormone testing: A blood specimen is tested to determine the level of testosterone and other male hormones.
  • Genetic testing: Genetic testing determines whether there is a genetic defect causing infertility.
  • Testicular biopsy: In unusual instances the doctor will recommend a testicular biopsy to identify abnormalities contributing to infertility.
  • Imaging: Imaging studies such as ultrasonography, a brain MRI, bone mineral density scan, or vasography (a test of the vas deferens) may be performed to detect structural defects.

Tests for women

Fertility for women relies on the ovaries releasing healthy eggs. Her reproductive tract must allow an egg to pass into her fallopian tubes and join with sperm for fertilization. The fertilized egg must travel to the uterus and implant in the lining. Tests for female infertility attempt to determine whether any of these processes are impaired.

You may have a general physical exam, including a regular gynecological exam. Specific fertility tests may include:

  • Ovulation testing. A blood test measures hormone levels to determine whether you’re ovulating.
  • Hysterosalpingography (his-tur-o-sal-ping-GOG-ruh-fee) evaluates the condition of your uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and ensure the fluid spills out of your fallopian tubes.
  • Ovarian reserve testing. This testing helps determine the quality and quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
  • Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as pituitary hormones that control reproductive processes.
  • Imaging tests. Pelvic ultrasound looks for uterine or fallopian tube disease. Sometimes a hysterosonography (his-tur-o-suh-NOG-ruh-fee) is used to see details inside the uterus that are not seen on a regular ultrasound.

Other additional testing which may be requested include:

  • Based on your symptoms, your doctor may request a hysteroscopy to look for uterine or fallopian tube disease. During hysteroscopy, your doctor inserts a thin, lighted device through your cervix into your uterus to view any potential abnormalities.
  • This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
  • Genetic testing. Genetic testing helps determine whether there’s a genetic defect causing infertility.

Luckily many of these tests will not be required before the cause of infertility is found. Your doctor will recommend the tests you will need to get done depending on your specific situation.

Treatment options

Infertility treatment depends on:

  • What’s causing the infertility
  • How long you’ve been infertile
  • Your age and your partner’s age
  • The client’s personal choice

Not all cases of infertility can be corrected by surgery or treatment. These cases may be candidates for a pregnancy and hopefully a successful outcome. Infertility treatment involve significant financial investment, physical and psychological interventions.

Treatment for men

For men, the treatment may include:

  • Lifestyle changes
  • Sex therapy, couples sex therapy
  • Smoking cessation
  • Change in prescription medication
  • Reducing/eliminating harmful substances
  • Increasing frequency and timing of intercourse
  • Weight loss which includes regular exercise
  • Medications

Medications such as testosterone may improve a man’s sperm count and his chances of achieving a successful pregnancy. The role of these medicines is to increase testicular function and by extension quality sperm production.

  • Surgery

Surgically repairing a varicocele has improved overall chances for pregnancy.

  • Sperm retrieval

Special techniques to harvest sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases where assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal. Sperm banking is a growing service.

Treatment for women

Although a woman may need just one or two therapies to restore fertility, it’s possible that several different types of treatment may be needed before she’s able to conceive.

  • Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
  • Intrauterine insemination (IUI). During IUI, healthy sperm are placed directly in the uterus around the time the woman’s ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
  • Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum or intrauterine scar tissue can be treated with hysteroscopic surgery.

Assisted reproductive technology

Assisted reproductive technology (ART) is any fertility treatment in which the egg and sperm are handled. An ART health team includes physicians, psychologists, embryologists, lab technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

In vitro fertilization (IVF) is the most common ART technique. IVF involves stimulating and retrieving multiple mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a lab, and implanting the embryos in the uterus three to five days after fertilization. an IVF cycle, such as:

Intracytoplasmic sperm injection (ICSI). A single healthy sperm is injected directly into a mature egg. ICSI is often used when there is poor se

  • Other techniques are sometimes used in men quality or quantity, or if fertilization attempts during prior IVF cycles failed.
  • Assisted hatching. This technique assists the implantation of the embryo into the lining of the uterus by opening the outer covering of the embryo (hatching).
  • Donor eggs or sperm. Most ART is done using the woman’s own eggs and her partner’s sperm. However, if there are severe problems with either the eggs or sperm, you may choose to use eggs, sperm or embryos from a known or anonymous donor.
  • Gestational carrier. Women who don’t have a functional uterus or for whom pregnancy poses a serious health risk might choose IVF using a gestational carrier. In this case, the couple’s embryo is placed in the uterus of the carrier for pregnancy.

Complications of treatment

Complications of infertility treatment may include:

  • Multiple pregnancy. The most common complication of infertility treatment is a multiple pregnancy — twins, triplets or more. Generally, the greater the number of fetuses, the higher the risk of premature labor and delivery, as well as problems during pregnancy such as gestational diabetes. Babies born prematurely are at increased risk of health and developmental problems. Talk to your doctor about ways to prevent a multiple pregnancy before you begin treatment.
  • Ovarian hyperstimulation syndrome (OHSS). Fertility medications to induce ovulation can cause OHSS, in which the ovaries become swollen and painful. Symptoms may include mild abdominal pain, bloating and nausea that lasts about a week, or longer if you become pregnant. Rarely, a more severe form causes rapid weight gain and shortness of breath requiring emergency treatment.
  • Bleeding or infection. As with any invasive procedure, there is a rare risk of bleeding or infection with assisted reproductive technology.

Psychological Issues associated with infertility

Infertility often creates one of the most distressing life crises that a couple has ever experienced together. The long term inability to conceive a child can evoke significant feelings of loss. Coping with the multitude of medical decisions and the uncertainties that infertility brings can create great emotional upheaval for most couples. If you find yourself feeling anxious, depressed, out of control, or isolated, you are not alone.

Everyone has feelings and emotional ups and downs as they pursue infertility treatment. Feeling overwhelmed at times is a perfectly normal response. However, if you experience any of the following symptoms over a prolonged period of time, you may benefit a great deal from working with a mental health professional:

  • loss of interest in usual activities
  • depression that doesn’t lift
  • strained interpersonal relationships (with partner, family, friends and/or colleagues)
  • difficulty thinking of anything other than your infertility
  • high levels of anxiety
  • diminished ability to accomplish tasks
  • difficulty with concentration
  • change in your sleep patterns (difficulty falling asleep or staying asleep, early morning awakening, sleeping more than usual for you)
  • change in your appetite or weight (increase or decrease)
  • increased use of drugs or alcohol
  • thoughts about death or suicide
  • social isolation
  • persistent feelings of pessimism, guilt, or worthlessness
  • persistent feelings of bitterness or anger

In addition, there are certain points during infertility treatment when discussion with a mental health professional of various options and exploration of your feelings about these options can help facilitate clarification of your thinking and help with your decision making. For example, consultation with a mental health professional may be helpful to you and your partner if you are:

  • at a treatment crossroad
  • deciding between alternative treatment possibilities
  • exploring other family building options
  • considering third party assistance (gamete donation, surrogacy)
  • having difficulty communicating or if you have different ideas about what direction to take

Mental health professionals with experience in infertility treatment can help a great deal. Their primary goal is to help individuals and couples learn how to cope with the physical and emotional changes associated with infertility, as well as with the medical treatments that can be painful and intrusive. For some, the focus may be on how to deal with a partner’s response. For others, it may be on how to choose the right medical treatment or how to begin exploring other family building options. For still others, it may be on how to control stress, anxiety, or depression. By teaching patients problem- solving strategies in a supportive environment, mental health professionals help people work through their grief, fear, and other emotions so that they can find resolution of their infertility. A good therapist can help you sort out feelings, strengthen already present coping skills and develop new ones, and communicate with others more clearly. For many, the life crisis of infertility eventually proves to be an opportunity for life-enhancing personal growth.

Finding a mental health professional experienced in working with infertility

Choose a mental health professional who is familiar with the emotional experience of infertility. Minimum requirements are:

  • a graduate degree in a mental health profession
  • a state registration licence to practice
  • clinical psychology training in infertility

Shop around by interviewing more than one person. Ask about their credentials and experience with infertility issues and treatments. Ask how many couples they have assisted with infertility issues. Colleagues and family may be able to highly recommend fertility professionals.

Fertility Herbs

There is few research on fertility herbs and supplements. Clinical results are inconclusive based on the number of small studies. Some of the fertility herbs and supplements studied include:

  • L-carnitine. For male infertility, some studies show increased sperm production and motility in men who took a combination of acetyl-L-carnitine and L-carnitine. But the resulting number of pregnancies was not statistically significant.
  • Vitamin E. An older study showed that men with low sperm counts who take vitamin E may have a higher rate of fertility than those taking a placebo, but this study had several dropouts in the placebo group, making comparison difficult. Other studies found no improvement in male fertility when vitamin E is combined with vitamin C or selenium.
  • Coenzyme Q10. A few studies have suggested that coenzyme Q10 may improve sperm counts or motility, but this was not shown to improve the chances of getting pregnant. More research is needed to confirm these findings and to determine whether such findings lead to improved fertility.
  • Folic acid. Although some research suggests that folic acid taken with zinc may improve sperm counts, more research is needed to determine if this will have an impact on conception.
  • Vitamin C. There isn’t enough reliable evidence to determine whether taking vitamin C has any impact on fertility. More research is needed to clarify whether vitamin C can improve fertility in men and women.

Although often marketed as “natural,” this doesn’t mean that herbal products are always safe. Consider these important issues about fertility herbs:

  • They have limited Food and Drug Administration regulation. Herbal and nutritional supplements are subjected to limited regulation by the Food and Drug Administration and are only now starting to be held to higher purity and quality standards.
  • They have a potential for drug interaction. Conventional hormone and drug treatments for infertility are complex regimens. It’s not known how herbs or supplements may interact with such treatments.
  • They may have side effects. Herbal and nutritional supplements may have side effects, especially when taken in larger doses. For example, too much vitamin C can cause significant gastrointestinal problems, and high daily intake of vitamin E could increase the risk of premature death in some people with chronic illnesses.

Talk to your doctor about any herbal or nutritional supplements you plan to take or are taking to find out the possible risks and benefits. Until researchers more clearly define the risks and benefits of fertility herbs and supplements, conventional treatment for infertility appears to be the best option.

Conservative ways to boost fertility

For women: Weight Control

Being underweight or overweight can delay the time it takes a woman to conceive.

William Gibbons, director of the division of reproductive endocrinology and infertility at Baylor College of Medicine, says weight before getting pregnant is often an overlooked factor in fertility. Keeping a healthy weight can help with conception.

In one study, researchers evaluated the body mass index (BMI) of 2,112 pregnant women. Women in the study who had a pre-pregnancy BMI of 25-39 – considered overweight or obese — had a twofold increase in the time it took to get pregnant. A BMI less than 19 (18.5 to 24.9 is considered normal) is even worse, the researchers found. Time to conception was increased fourfold in women with a BMI below 19.

Gibbons tells women to stay at a healthy weight when trying to conceive.

For men: Protect Those Sperm

According to Dale McClure, president of the American Society for Reproductive Medicine, the idea that changing to boxers instead of briefs will boost fertility by keeping genital temperatures down is basically an old wives’ tale. Earlier studies seemed to point to boxers as the better choice, McClure says. But more recent studies haven’t shown a major difference.

What about exposing the testicles to other sources of heat? The American Society for Reproductive Medicine says controlling temperature doesn’t play much of role in boosting fertility. Some doctors, though, recommend staying away from certain sources. For instance, sitting in a hot tub day after day should be avoided, McClure says, even if a man has no known fertility problems. In at least one study, repeated exposure to high water temperatures through hot tubs or hot baths was shown to affect men’s fertility.

Still, no research has clearly shown a link between exposure to other sources of heat and a man’s fertility. One study did show that scrotal temperatures went up in laptop users who held the computer on their laps and warned that long-term exposures to high temperatures could harm sperm. Another study found that exposure to radiation from cell phones could adversely affect sperm that had been collected from participants. Researchers in that study speculated that keeping a cell phone in a pants pocket could affect the health of a man’s sperm.

While neither study was sufficient to prove that exposure to sources of heat could harm sperm enough to affect fertility, McClure still says a man who wants to be a father probably shouldn’t keep his laptop on his lap for extended periods of time. But even considering the above findings, McClure says he is “more concerned about hot tubbing.”

For the woman’s fertility booster: What those beverage as especially alcohol and caffeine in large quantities can affect fertility. Once pregnant she should cut alcohol completely.

Rule of thumb for couples’ fertility

  • For couples’ fertility booster: Stop smoking:
    • Smoking impairs fertility in males and females
    • Smoking affects how receptive the uterus iss to the egg
    • Smoking decreases the sperm count and damages DNA
    • Smoking while pregnant increases the risk of miscarriages
    • A woman who plans to get pregnant should stop smoking

 

  • The fertile window is three (3) days before ovulation
  • Have sex frequently
  • Choose lubricants wisely
  • Avoid lubricants with spermicidal agent
  • Avoid pesticides and other harmful exposure

 Bibliography for Research on Fertility
1.      The effect of obesity on the outcome of infertility management in women with polycystic ovary syndrome

M Al-Azemi, FE Omu, AE Omu – Archives of gynecology and obstetrics, 2004 – Springer

2.      Aromatase inhibition for ovarian stimulation : future avenues for infertility management

MF Mitwally, RF Casper – Current Opinion in Obstetrics and …, 2002 – journals.lww.com

3.      [HTML] Attenuation of oxidative stress and DNA damage in varicocelectomy : implications in infertility management

R Dada, MB Shamsi, S Venkatesh, NP Gupta… – The Indian journal of …, 2010 – ijmr.org.in

4.      Do clinical guidelines improve general practice management and referral of infertile couples ?

C Emslie, J Grimshaw, A Templeton – BMJ, 1993 – bmj.com

5.      The role of ultrasound in female infertility management

BJ Hackelöer – Ultrasound in medicine & biology, 1984 – Elsevier

6.      The future of male infertility management and assisted reproduction technology

D Mortimer – Human reproduction, 2000 – ESHRE

7.      Impact of overweight and underweight on assisted reproduction treatment

P Fedorcsák, PO Dale, R Storeng, G Ertzeid… – … Reproduction, 2004 – ESHRE

8.      International estimates of infertility prevalence and treatment seeking : potential need and demand for infertility medical care

J Boivin, L Bunting, JA Collins, KG Nygren – Human reproduction, 2007 – ESHRE

9.      Surgery or assisted reproduction ? A decision analysis of treatment costs in male infertility

MV Meng, KL Greene, PJ Turek – The Journal of urology, 2005 – Elsevier

10.  Weight loss in obese infertile women results in improvement in reproductive outcome for all forms of fertility treatment

AM Clark, B Thornley, L Tomlinson, C Galletley… – … Reproduction, 1998 – ESHRE

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