infertility

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Infertility

 

Definition

Infertility is the failure of a couple to conceive a pregnancy after trying to do so for at least one full year. In primary infertility, pregnancy has never occurred. In secondary infertility, one or both members of the couple have previously conceived, but are unable to conceive again after a full year of trying.

Description

Currently, in the United States, about 20% of couples struggle with infertility at any given time. Infertility has increased as a problem over the last 30 years. Some studies pin the blame for this increase on social phenomena, including the tendency for marriage to occur at a later age, which means that couples are trying to start families at a later age. It is well known that fertility in women decreases with increasing age, as illustrated by the following statistics:
  • Infertility in married women ages 16-20 = 4.5%
  • Infertility in married women ages 35-40 = 31.8%
  • Infertility in married women over the age of 40 = 70%.
Today, individuals often have multiple sexual partners before they marry and try to have children. This increase in numbers of sexual partners has led to an increase in sexually transmitted diseases. Scarring from these infections, especially from pelvic inflammatory disease (a serious infection of the female reproductive organs, most commonly caused by gonorrhea) seems to be in part responsible for the increase in infertility noted. Furthermore, use of some forms of a contraceptive called the intrauterine device (IUD) contributed to an increased rate of pelvic inflammatory disease, with subsequent scarring. However, newer IUDs do not lead to this increased rate of infection.
To understand issues of infertility, it is first necessary to understand the basics of human reproduction. Fertilization occurs when a sperm from the male merges with an egg (ovum) from the female, creating a zygote that contains genetic material (DNA) from both the father and the mother. If pregnancy is then established, the zygote will develop into an embryo, then a fetus, and ultimately a baby will be born.
The male contribution to fertilization and the establishment of pregnancy is the sperm. Sperm are small cells that carry the father's genetic material. This genetic material is contained within the oval head of the sperm. The sperm are mixed into a fluid called semen, which is discharged from the penis during sexual intercourse. The whip-like tail of the sperm allows the sperm to swim up the female reproductive tract, in search of the egg it will try to fertilize.
The female makes many contributions to fertilization and the establishment of pregnancy. The ovum is the cell that carries the mother's genetic material. These ova develop within the ovaries. Once a month, a single mature ovum is produced, and leaves the ovary in a process called ovulation. This ovum enters a tube leading to the uterus (the fallopian tube). The ovum needs to meet up with the sperm in the fallopian tube if fertilization is to occur.
When fertilization occurs, the resulting cell (which now contains genetic material from both the mother and the father) is called the zygote. This single cell will divide into multiple other cells within the fallopian tube, and the resulting cluster of cells (called a blastocyst) will then move into the womb (uterus). The uterine lining (endometrium) has been preparing itself to receive a pregnancy by growing thicker. If the blastocyst successfully reaches the inside of the uterus and attaches itself to the wall of the uterus, then implantation and pregnancy have been achieved.

Causes and symptoms

Unlike most medical problems, infertility is an issue requiring the careful evaluation of two separate individuals, as well as an evaluation of their interactions with each other. In about 3-4% of couples, no cause for their infertility will be discovered. About 40% of the time, the root of the couple's infertility is due to a problem with the male partner; about 40% of the time, the root of the infertility is due to the female partner; and about 20% of the time, there are fertility problems with both the man and the woman. Recently, a study in Great Britain reported that smoking adds to infertility problems for both men and women. In addition, men and women who smoke are less likely to respond to infertility treatment.
The main factors involved in causing infertility, listing from the most to the least common, include:
  • Male problems: 35%
  • Ovulation problems: 20%
  • Tubal problems: 20%
  • Endometriosis: 10%
  • Cervical factors: 5%.

Male factors

Male infertility can be caused by a number of different characteristics of the sperm. To check for these characteristics, a sample of semen is obtained and examined under the microscope (semen analysis). Four basic characteristics are usually evaluated:
  • Sperm count refers to the number of sperm present in a semen sample. The normal number of sperm present in just one milliliter (ml) of semen is more than 20 million. An individual with only 5-20 million sperm per ml of semen is considered subfertile, an individual with less than 5 million sperm per ml of semen is considered infertile.
  • Sperm are also examined to see how well they swim (sperm motility) and to be sure that most have normal structure.
  • Not all sperm within a specimen of semen will be perfectly normal. Some may be immature, and some may have abnormalities of the head or tail. A normal semen sample will contain no more than 25% abnormal forms of sperm.
  • Volume of the semen sample is important. An abnormal amount of semen could affect the ability of the sperm to successfully fertilize an ovum.
Another test can be performed to evaluate the ability of the sperm to penetrate the outer coat of the ovum. This is done by observing whether sperm in a semen sample can penetrate the outer coat of a guinea pig ovum; fertilization cannot occur, of course, but this test is useful in predicting the ability of the individual's sperm to penetrate a human ovum.
Any number of conditions result in abnormal findings in the semen analysis. Men can be born with testicles that have not descended properly from the abdominal cavity (where testicles develop originally) into the scrotal sac, or may be born with only one instead of the normal two testicles. Testicle size can be smaller than normal. Past infection (including mumps) can affect testicular function, as can a past injury. The presence of abnormally large veins (varicocele) in the testicles can increase testicular temperature, which decreases sperm count. History of having been exposed to various toxins, drug use, excess alcohol use, use of anabolic steroids, certain medications, diabetes, thyroid problems, or other endocrine disturbances can have direct effects on the formation of sperm (spermatogenesis). Problems with the male anatomy can cause sperm to be ejaculated not out of the penis, but into the bladder, and scarring from past infections can interfere with ejaculation.
Treatment of male infertility includes addressing known reversible factors first; for example, discontinuing any medication known to have an effect on spermatogenesis or ejaculation, as well as decreasing alcohol intake, and treating thyroid or other endocrine disease. Varicoceles can be treated surgically. Testosterone in low doses can improve sperm motility.
Other treatments of male infertility include collecting semen samples from multiple ejaculations, after which the semen is put through a process that allows the most motile sperm to be sorted out. These motile sperm are pooled together to create a concentrate that can be deposited into the female partner's uterus at a time that coincides with ovulation. In cases where the male partner's sperm is proven to be absolutely unable to cause pregnancy in the female partner, and with the consent of both partners, donor sperm may be used for this process. Depositing the male partner's sperm or donor sperm by mechanical means into the female partner are both forms of artificial insemination.

Ovulatory problems

The first step in diagnosing ovulatory problems is to make sure that an ovum is being produced each month. A woman's morning body temperature is slightly higher around the time of ovulation. A woman can measure and record her temperatures daily and a chart can be drawn to show whether or not ovulation has occurred. Luteinizing hormone (LH) is released just before ovulation. A simple urine test can be done to check if LH has been released around the time that ovulation is expected.
Treatment of ovulatory problems depends on the cause. If a thyroid or pituitary problem is responsible, simply treating that problem can restore fertility. (The thyroid and pituitary glands release hormones that also are involved in regulating a woman's menstrual cycle.) Medication can also be used to stimulate fertility. The most commonly used of these are called Clomid and Pergonal. These drugs increase the risk of multiple births (twins, triplets, etc.). Other possible medications include gonadotropin medications, which are injected medications made up of hormones produced in the pituitary glands. They may directly stimulate the ovaries to produce eggs. Follicle stimulating hormone (FSH) has a 95% chance of simulating ovulation in women with an ovulatory problem. However, its use does not guarantee a successful pregnancy and may lead to multiple pregnancies.

Pelvic adhesions and endometriosis

Pelvic adhesions and endometriosis can cause infertility by preventing the sperm from reaching the egg or interfering with fertilization.
Pelvic adhesions are fibrous scars. These scars can be the result of past infections, such as pelvic inflammatory disease, or infections following abortions or prior births. Previous surgeries can also leave behind scarring.
Endometriosis may lead to pelvic adhesions. Endometriosis is the abnormal location of uterine tissue outside of the uterus. When uterine tissue is planted elsewhere in the pelvis, it still bleeds on a monthly basis with the start of the normal menstrual period. This leads to irritation within the pelvis around the site of this abnormal tissue and bleeding, and may cause scarring.
Pelvic adhesions cause infertility by blocking the fallopian tubes. The ovum may be prevented from traveling down the fallopian tube from the ovary or the sperm may be prevented from traveling up the fallopian tube from the uterus.
A hysterosalpingogram (HSG) can show if the fallopian tubes are blocked. This is an x-ray exam that tests whether dye material can travel through the patient's fallopian tubes. A few women become pregnant following this x-ray exam. It is thought that the dye material in some way helps flush out the tubes, decreasing any existing obstruction. Scarring also can be diagnosed by examining the pelvic area through the use of a scope that can be inserted into the abdomen through a tiny incision made near the naval. This scoping technique is called laparoscopy.
Pelvic adhesions can be treated during laparoscopy. The adhesions are cut using special instruments. Endometriosis can be treated with certain medications, but may also require surgery to repair any obstruction caused by adhesions.

Cervical factors

The cervix is the opening from the vagina into the uterus through which the sperm must pass. Mucus produced by the cervix helps to transport the sperm into the uterus. Injury to the cervix or scarring of the cervix after surgery or infection can result in a smaller than normal cervical opening, making it difficult for the sperm to enter. Injury or infection can also decrease the number of glands in the cervix, leading to a smaller amount of cervical mucus. In other situations, the mucus produced is the wrong consistency (perhaps too thick) to allow sperm to travel through. In addition, some women produce antibodies (immune cells) that are specifically directed to identify sperm as foreign invaders and to kill them.
Cervical mucus can be examined under a microscope to diagnose whether cervical factors are contributing to infertility. The interaction of a live sperm sample from the male partner and a sample of cervical mucus from the female partner can also be examined. This procedure is called a post-coital test.
Treatment of cervical factors includes antibiotics in the case of an infection, steroids to decrease production of anti-sperm antibodies, and artificial insemination techniques to completely bypass the cervical mucus.
A. An egg and sperm are injected into the fallopian tube to encourage natural fertilization in a procedure called gamete intrafallopian transfer (GIFT). B. An alternative to GIFT is the injection of sperm directly into an egg using microscopic needles.
A. An egg and sperm are injected into the fallopian tube to encourage natural fertilization in a procedure called gamete intrafallopian transfer (GIFT). B. An alternative to GIFT is the injection of sperm directly into an egg using microscopic needles.
(Illustration by Argosy Inc.)

Treatment

Assisted reproductive techniques include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian tube transfer (ZIFT). These are usually used after other techniques to treat infertility have failed.
In vitro fertilization involves the use of a drug to induce the simultaneous release of many eggs from the female's ovaries, which are retrieved surgically. Meanwhile, several semen samples are obtained from the male partner, and a sperm concentrate is prepared. The ova and sperm are then combined in a laboratory, where several of the ova may be fertilized. Cell division is allowed to take place up to the embryo stage. While this takes place, the female may be given drugs to ensure that her uterus is ready to receive an embryo. Three or four of the embryos are transferred to the female's uterus, and the wait begins to see if any or all of them implant and result in an actual pregnancy.
Success rates of IVF are still rather low. Most centers report pregnancy rates between 10-20%. Since most IVF procedures put more than one embryo into the uterus, the chance for a multiple birth (twins or more) is greatly increased in couples undergoing IVF.
GIFT involves retrieval of both multiple ova and semen, and the mechanical placement of both within the female partner's fallopian tubes, where one hopes that fertilization will occur. ZIFT involves the same retrieval of ova and semen, and fertilization and growth in the laboratory up to the zygote stage, at which point the zygotes are placed in the fallopian tubes. Both GIFT and ZIFT seem to have higher success rates than IVF.

Prognosis

It is very hard to obtain statistics regarding the prognosis of infertility because many different problems may exist within and individual or couple trying to conceive. In general, it is believed that of all couples who undergo a complete evaluation of infertility followed by treatment, about half will ultimately have a successful pregnancy. Of those couples who do not choose to undergo evaluation or treatment, about 5% will go on to conceive after a year or more of infertility.

Resources

Books

Martin, Mary C. "Infertility." In Current Obstetric and Gynecologic Diagnosis and Treatment, edited by Alan H. Cecherney and Martin L. Pernoll. Norwalk, CT: 1994.

Periodicals

"Infertility; Treatment." NWHRC Health Center March 10, 2004.
Kmietowicz, Zosia. "Smoking is Causing Impotence, Miscarriages, and Infertility." British Medical Journal February 14, 2004: 364.

Organizations

American Society for Reproductive Medicine. 1209 Montgomery Highway, Birmingham, AL 35216-2809. (205) 978-5000. http://www.asrm.com.
International Center for Infertility Information Dissemination. http://www.inciid.org.

Key terms

Blastocyst — A cluster of cells representing multiple cell divisions that have occurred in the fallopian tube after successful fertilization of an ovum by a sperm. This is the developmental form which must leave the fallopian tube, enter the uterus, and implant itself in the uterus to achieve actual pregnancy.
Cervix — The opening from the vagina, which leads into the uterus.
Embryo — The stage of development of a baby between the second and eighth weeks after conception.
Endometrium — The lining of the uterus.
Fallopian tube — The tube leading from the ovary into the uterus. Just as there are two ovaries, there are two Fallopian tubes.
Fetus — A baby developing in the uterus from the third month to birth.
Ovary — The female organ in which eggs (ova) are stored and mature.
Ovum (plural: ova) — The reproductive cell of the female, which contains genetic information and participates in the act of fertilization. Also popularly called the egg.
Semen — The fluid that contains sperm, which is ejaculated by the male.
Sperm — The reproductive cell of the male, which contains genetic information and participates in the act of fertilization of an ovum.
Spermatogenesis — The process by which sperm develop to become mature sperm, capable of fertilizing an ovum.
Zygote — The result of the sperm successfully fertilizing the ovum. The zygote is a single cell that contains the genetic material of both the mother and the father.

infertility

 [in″fer-til´ĭ-te]
the inability to conceive and produce viable offspring. adj., adj infer´tile. The diagnosis of infertility is not usually considered valid until after one year of engaging in sexual relations with the same partner without contraception. Formerly, a couple's inability to have children was almost always ascribed to infertility in the female. It is now known that about 35 per cent of the cases of infertility are due to male factors, about 35 per cent to female factors, and the remaining 30 per cent to a combination of male and female factors. Most specialists subject both partners to an infertility study. More than half the couples who consult a specialist with a problem of infertility can achieve a live birth. About 5 per cent become fertile spontaneously without any treatment.

Diagnostic tests commonly used to identify female-related causes of infertility include a general pelvic examination, culdoscopy, and laparoscopy. In order to check ovulation, the health care provider may ask the patient to keep a basal temperature chart or, if indicated, an endometrial biopsy may be performed.

One cause of infertility is infection or obstruction within the fallopian tubes. The principal infections are gonorrhea and tuberculosis. A rare occurrence is the growth of a tumor in a tube. Tests to determine tubal patency include the Rubin test, which involves injecting carbon dioxide into the uterus under controlled pressure. The gas goes into the tubes and, if the tubes are open, escapes into the abdomen, from which it is harmlessly discharged. In some cases, it is thought that the gas may unblock obstructed fallopian tubes, as well as detect them. Similar information is obtained by hysterosalpingography, in which a radiopaque material is instilled into the uterus and fallopian tubes and x-rays of the structures are obtained.

Direct inspection of the cervix can be helpful in finding infections and chronic inflammations that could prevent conception. A postcoital test called the huhner test gives information about the ability of the sperm to survive in the cervical mucus.

Tests to identify male-related factors causing infertility include semen analysis to determine the number and motility of sperm. A low or absent sperm count could be caused by trauma to the sperm-producing cells, as in excessively high temperature of the scrotal sac resulting from inflammation, or radioactive damage to the cells. Certain drugs can also adversely affect the sperm-producing cells. Chronic prostatitis, prostatectomy, and hormonal factors can decrease motility of the sperm. A stricture in the vas deferens blocks the transporting of sperm. Strictures can result from infection, trauma, and congenital malformations. Deposition of the sperm in the vaginal tract can be hindered by premature ejaculation, impotence, and congenital malformations of the penis.

Both partners are usually given a general physical examination and a complete sexual history is taken. Painful intercourse (dyspareunia) can contribute to infertility by diminishing the frequency of intercourse. This condition can be due to malfunction of the glands that lubricate the vaginal wall. The difficulty can also be psychologic in origin, the result of sexual fears or inhibition. The most serious condition of this type is vaginismus, in which the muscles in the vagina contract, blocking the entry of the penis and making penetration impossible.

In addition to the sexual history, a medical history can raise a suspicion of an endocrine disorder, for example, hypothyroidism, or a genetic disorder, such as Turner's syndrome in women and Klinefelter's syndrome in men. If a chromosomal disorder is suspected, a buccal smear may be done for chromosomal studies.
Treatment. Treatment for relieving infertility is highly individualized. Detection of the cause and prescription of treatment should be conducted by a specialist in the area of fertility, who is better informed than general practitioners about current methods of diagnosis and treatment, and should be supportive of both partners. Feelings of anger, helplessness, grief, and other emotions can be very intense and may require great understanding and support. Either partner may feel that infertility is a threat to his or her sexuality and sexual self-image.

If the infertility cannot be corrected, as in women who fail to ovulate or men who have no sperm-producing cells, there are alternatives. Adoption is becoming more difficult because of the availability of birth control methods and the fact that more than 70 per cent of unwed mothers now choose to keep and raise their children themselves. Artificial insemination is an alternative for couples who have no moral or religious objection to the procedure. Since there is less social pressure to have children in modern Western cultures, some couples do not consider infertility a problem.

in·fer·til·i·ty

(in'fĕr-til'i-tē),
Diminished or absent ability to produce offspring; in either the male or the female, not as irreversible as sterility.
[L. in- neg. + fertilis, fruitful]

infertility

/in·fer·til·i·ty/ (in″fer-til´ĭ-te) diminution or absence of ability to produce offspring.infer´tile
immunologic infertility  any of several types believed to be caused by presence in the female of antibodies that interfere with functioning of the sperm.

infertility

(ĭn′fər-tĭl′ĭ-tē)
n.
1. Absent or diminished fertility.
2. The persistent inability to conceive a child.

infertility

[in′furtil′itē]
the condition of being unable to produce offspring. Compare sterility.

infertility

Gynecology The inability to produce children; the involuntary inability to conceive, which contrasts to sterility, the complete inability to reproduce; 8.5% of married couples–US are infertile– or inconceivable. See Assisted reproduction, Hemizona assay, In vitro fertilization, Involuntary infertility, Mechanical infertility, Sperm penetration assay.

in·fer·til·i·ty

(in'fĕr-til'i-tē)
Diminished ability to produce offspring; does not imply sterility.
[L. in- neg. + fertilis, fruitful]

infertility

The apparent inability of a particular couple to reproduce. The problem may rest either with the female or with the male or, rarely, with both. Male causes are largely confined to a low sperm count or abnormal sperms and cigarette smoking. So the first step in investigation is to investigate this by examination of a sample of seminal fluid. Female causes are more numerous and include age over 35, failure of ovulation, blockage of the fallopian tubes, uterine fibroids, adhesions within the womb, sperm-hostile mucus in the cervix, thyroid disorders, diabetes, obesity, and excessive physical exercise. Joint causes include cigarette smoking, excessive caffeine intake, use of recreational drugs and ignorance of basic reproductive knowledge.

infertility,

n the inability to produce offspring. Causes can be complex and varied, and a wide range of treatment options are used.

in·fer·til·i·ty

(in'fĕr-til'i-tē)
Diminished or absent ability to produce offspring.
[L. in- neg. + fertilis, fruitful]

infertility

the inability to conceive and produce viable offspring. In agricultural animals there are requirements that the animals reproduce prolifically and at a particular time chosen to best suit the availability of feed. A decision as to when infertility can be said to be present varies with the species and with the mating pair, and also with the state of the environment. For example, a dairy cow mated three times without conceiving to proven fertile semen by artificial insemination or by natural breeding to a known fertile bull is judged to require treatment for infertility. Infertility is a diagnosis about a mating rather than an individual animal; the error may be with the male or the female and it may be permanent or temporary. As a herd problem it provides a major brake on production in all species. In many instances the problem is man-made and in many of those there is in fact nothing wrong with the animals but there is with the management program, especially the nutritional regimen, which affects a mating at a time when fertility is marginal.

Patient discussion about infertility

Q. can staphylococcus in woman cause infertility? staphylococcus/infertility

A. Not that I know about. One of the major routes in which bacteria cause infertility in women is through inflammation of the pelvis (PID), but staphylococcus isn't a major cause of this disease.

You may read more here:
http://www.nlm.nih.gov/medlineplus/ency/article/000888.htm

Q. help program for infertil couple MY NAME IS ALEX AND I'M 44 YEARDS OLD AND MY WIFE IS NILDA AND SHE IS 41 YEARS OLD

A. Your infertility treatment plan will depend on the cause or causes behind your infertility. Infertility treatment also depends on whether the problem is from the woman’s side, the man’s side, both sides, or remains unexplained.The good news is that 85% to 90% of couples dealing with infertility are treated with low-tech treatments, like medication or surgery, with less than 3% being treated by Assisted Reproductive Technologies, like IVF. Of those treated for infertility, two-thirds will go onto have a baby. A common cause of infertility in women, ovulation disorders account for about 25% of female factor infertility cases. The first line of treatment for most women with ovulation problems is through medication. Fertility drugs can help a woman ovulate 80% of the time. For the full article: http://infertility.about.com/od/infertilitytreatments/a/basictreatments.htm Hope this helps.

Q. Is it possible to have babies after getting chemo? I heard it makes you infertile…

A. It is correct, both chemotherapy and radiation therapy can damage both male and female reproduction cells and cause infertility. That is because of the large toxic effect these treatments have on fast dividing cellsin the body. However, before starting therapy usually they take out both eggs or sperms from the patient and freeze them, in order to allow maintanence of healthy cells for the future in case they would like to have children.

More discussions about infertility