Causes of Infertility

Male Infertility

How Common is Male Infertility?

Abnormalities in male are the sole cause of infertility in approximately 20% of infertile couples and are an important contributing factor in another 20-40% of couples with Reproductive failure. If the sperm count or motility is extremely low, we usually assume this is the cause of fertility issue. But it may only be a contributing factor if the count or the motility is slightly low.

What are the causes of Male Infertility?

A. Chromosomal (Genetic Causes)

B. Testicular

  • Varicocele
  • Orchitis (Infection or Inflammation of testis)
  • Injury
  • Vasal Obstruction
  • Radiation / Chemotherapy damage to testis
  • Drugs or Gonadotoxins

C. Hormonal

It is characterized by inadequate stimulation of otherwise normal testicles and genital tract.

D. Others

  • Erectile problems
  • Ejaculatory problems
  • Vasectomy
  • Nerve injuries
  • Penile abnormalities
  • General debilities disease
  • Obesity, Smoking, Diet and Psychological factors

How do we investigate a Male Infertility Patient?

The basic and the most important test to evaluate Male Infertility is Semen Analysis. It may have to be repeated two or even 3 times to get an accurate reflection of the parameters. Semen parameters can vary widely over time, even among fertile men. Semen sample should be provided after 2-3 days of abstinence.

What is Azoospermia?

    • Azoospermia is absence of sperm on standard microscopic examination.
    • Oligospermia is sperm concentration < 20 million / ml
    • Aspermia is no Semen volume
    • Asthenospermia is fewer than 50% spermatozoa with forward progression
    • Teratospermia is fewer than 50% spermatozoa with normal morphology

What is Varicocele?

    • Varicocele is an abnormal tortuosity and dilatation of veins of the pampiniform plexus within the spermatic cord. The prevalence of varicocele is approximately 15% in the normal male population and about 40% in infertile men. Treatment options for men with abnormal Semen quality associated with a palpable varicocele include surgical repair, IUI, and IVF with or without ICSI. The best choice among these options depends on the age of the female partner and presence of other Infertility factors. The results achieved with varicocele repair have varied widely and convincing evidence for improved fertility is still lacking.

How to treat Male Infertility?

In mild to moderately low sperm count and or motility we do Ovulation Induction and Insemination (IUI) for about 3-6 months. If the patient doesn’t get pregnant after 3-6 months than IVF /ICSI is to be considered. In cases of severely low counts and or motility the treatment of choice is IVF / ICSI.

What is Donor Insemination?

It is an effective treatment for male factor Infertility. Donor Semen Samples are taken from the semen banks where all donors are screened for infectious diseases. The Semen is frozen and kept for a period of 6 months, so that donor can be again tested for HIV. We don’t do Donor Inseminations with fresh semen samples as this can be hazardous to patient’s health. With the new options for treating male infertility like ICSI, the need for Donor Insemination has decreased. But still it is a viable option for couples who cannot afford ICSI.

Ovulation Dyfunction

What is Tubal factor Infertility?

It involves any anatomic abnormalities in the Tubes that prevent union of sperm and ovum. These include cases of completely blocked fallopian tubes, cases with either one blocked tube or tubal scarring or other damage. The Tubal and peritoneal pathology is among the most common causes of Infertility and is present in approximately 30-35% of Infertile Couples.

What are the causes of Tubal Damage?

The major cause of Tubal factor infertility is PID (Pelvic Inflammatory disease) and the Pelvic Infections Tuberculosis is still an important cause of Tubal damage in India. Other causes are Inflammation due to endometriosis, inflammatory bowel disease or surgical Trauma.

What is treatment for Tubal factor Infertility?

Initial investigation to detect Tubal damage is HSG (hysterosalpingography). In this procedure contrast material (dye) is injected through the cervix to the uterine cavity and if the fallopian tubes are open the dye flows in the abdominal cavity through the tubes. This is documented with x-ray pictures during the procedure. Other method of detecting Tubal damage and peritoneal adhesions is Laparoscopy.

What are the methods of detecting Tubal Damage?

The treatment options for patient with Tubal factor Infertility is Tubal surgery or IVF. Tubal surgery is a good option for women seeking pregnancy after a previous tubal sterilization, for those with mild distal Tubal disease and women with apparent proximal tubal occlusion.

Endometriosis

What is Endometriosis?

It is a disorder in which endometrial tissue or lining of the uterus grows outside the uterus such as the ovaries or elsewhere in the abdominal cavity.

What are the symptoms of Endometriosis?

Progressively increasing dyspareunia may be a symptom of endometriosis. Others are dyspareunia or pain during intercourse and pelvic congestion.

How does endometriosis cause Infertility?

In mild cases the relationship with Infertility is Controversial. It may lead to mild Inflammation within the pelvic. In severe cases, it affects conception in various ways. It causes adhesions & scarring. These adhesions may involve the ovaries, fallopian tubes and the Intestines & thus interfere with the release of eggs from the ovaries or the ability of the tubes to pick up the egg. Ovulation may also be affected by the presence of chocolate cysts.

How to diagnose Endometriosis?

Diagnosis can be made on the basis of symptoms. In a symptomatic patient it is often diagnosed on Ultrasound scanning which can pick up the chocolate cysts in ovaries. To confirm the diagnosis Laparoscopy is the gold standard.

How is Endometriosis treated when as a cause of Infertility?

Treatment of Endometriosis when related to Infertility depends on the severity of disease and its location in the pelvis, presence of symptoms, the age of the women and the length of Infertility.

For patients with mild to moderate endometriosis associated with Infertility, ovulation Induction and IUI is done. If pregnancy is not achieved even after 6 cycles of treatment then IVF is the treatment of choice.

Medical treatment (GnRH – agonist) and surgical treatment can be undertaken but the pregnancy rates vary. In cases of severe Endometriosis where pelvic anatomy is distorted, patient will often require IVF.

Uterine Factors

What are the uterine problems which can affect the fertility?

Abnormalities of the uterus are relatively uncommon cause of infertility. But when present they can adversely affect the fertility.

  • Congenital Uterine malformations such as Septate Uterus or bicornuate Uterus
  • Uterine Fibroids
  • Intra uterine Synechiae or adhesions
  • Chronic Endometritis
  • Luteal phase defect
  • Thin endometrial linning

How to diagnose Uterine factors as a cause of Infertility?

There are 3 methods to evaluate the uterine cavity:

  • HSG (hysterosalpingography)
  • Trans Vaginal Ultrasound
  • Hysteroscopy

Unexplained Infertility

What is unexplained Infertility?

Unexplained Infertility is labeled when all the standard Infertility evaluation yields normal results. The incidence of unexplained Infertility ranges from 10% to as high as 30% among infertile population.

What are the treatment options for Unexplained Infertility?

1. Ovarian stimulation and IUI

There are increased chances of pregnancy with IUI for Unexplained Infertility as compared to timed intercourse.

2. Injectable gonadotropins (FSH hormone) plus Intrauterine Insemination

3. IVF

Premature Ovarian Failure

What is premature ovarian failure?

The cessation of normal functioning of ovaries in a woman under age of 40 years. This is confirmed by high FSH levels and low estrogen hormone levels.

What are the symptoms of premature ovarian failure?

The most common first symptom of ovarian failure is Irregular period or Amenorrhea. Others are infertility, hot flushes and might sweats, irritability and dryness of vagina.

How to diagnose premature ovarian failure?

As the first symptom is irregular periods, menstrual history is important in diagnosis. Hormonal studies are done, High FSH levels above about 30-40 IU indicates ovarian insufficiency. In addition a serum AMH level (Anti Mullerian) and ovarian Antral follicle Count is also low.

Can a patient of premature ovarian failure get pregnant?

Currently there is no effective treatment that will result in a pregnancy with her own eggs in a patient of premature ovarian failure.

Egg donation with IVF can be a very effective therapy for these patients.

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