FEMALE INFERTILITY

A: In the past, infertility was commonly considered to be solely a female problem. It is now recognized that a couple’s infertility is just as likely to stem from problems in the male partner. After couples with infertility undergo testing, about 40 percent of the cases are found to stem from female factors and another 40 percent from male factors.

In 10 percent of couples, infertility factors are found in both the man and woman. In the remaining 10 percent, the infertility remains unexplained after testing.

Because either or both may be involved, it is important to test both the man and woman before starting treatment. No matter what the cause, most treatments require the active participation of both partners.

A: Female Infertility is difficulty in conceiving a pregnancy. This general term does not identify the cause of the problem or whether it will be permanent.

Often, physicians and researchers consider a couple to have infertility if they have not conceived, despite regular intercourse without using birth control, for at least a year. Fifteen to 20 percent of couples will not conceive despite a year of trying. However, this does not mean that they will not conceive later on, even without treatment.

A: Yes. Secondary infertility is the name given when the problem arises in a couple who have been able to get pregnant in the past. Sometimes a new factor, such as an infection, has damaged the reproductive organs since the last child was born. Sometimes the aging process makes it more difficult for a couple to conceive, even if they had no problems when they were younger.

Secondary infertility is even more common than infertility in couples who have never achieved a pregnancy.

Generally, the diagnosis and treatment is the same. However, couples with secondary infertility may make different treatment choices as they take into account the needs of their other children. Overall, treatments are somewhat more likely to work in women with secondary infertility than in women who have not previously become pregnant with the same partner.

A: For a couple to conceive and carry a pregnancy, four parts of the reproductive system must be working adequately:

   A woman’s ovaries must be regularly producing and releasing good-quality eggs.

   Normal sperm must be produced in high enough numbers and delivered during sexual intercourse.

The reproductive passageways must be clear enough for:

a) sperm to enter the uterus (through the cervix) and swim into the tubes to unite with the egg;

b) the egg or early embryo to travel to the uterus (through the Fallopian tubes).

The lining of the uterus must be capable of having the embryo implant, and of sustaining the pregnancy.

Many types of problems – including hormone abnormalities or blockages caused by infection or scar tissue – can affect one or more of these functions.

A: Yes. According to recent national data, about 10-15 per cent of couples in India are said to have fertility issues due to multiple factors.

A: In general, women’s fertility begins to decline gradually after age 30, with a steep drop between 35 and 45. This means that, on average, it takes longer for an older woman to conceive, and older women are more likely to be diagnosed with infertility. Pregnancies in older women are also more likely to miscarry.

The most predictable age-related change is a gradual reduction in the number and quality of eggs produced as a woman enters her late thirties. As she nears menopause, eggs are not released in more and more of a woman’s menstrual cycles, making conception impossible.

Also, as women age, they are more likely to have had illnesses or medical treatments that can compromise fertility. Some of these affect the reproductive system directly, such as endometriosis, sexually transmitted diseases (STDs), surgery on the reproductive organs, or ectopic pregnancies. Others are general medical problems that can damage fertility, such as hypothyroidism, high blood pressure, diabetes and lupus.

As they age, men may also be exposed to infections, medications, or occupational or environmental chemicals that can impair fertility. However, they do not experience the same dramatic and predictable age-related decline as women.

Because of the increased possibility of fertility problems, women over the age of 35 are often counselled to seek medical advice if they attempt to conceive for six months without success. However, because conception is likely to take longer in older women, some experts suggest that couples give themselves more, rather than less, time to conceive before seeking medical help.

Couples must find a balance between not allowing enough time for conception and delaying too long (making treatment less likely to succeed).

A: Sometimes. By learning about the known causes of infertility, young men and women can reduce the risk that they will face this challenge when they decide to start a family. Some strategies for prevention:

Take precautions (such as the use of condoms) to avoid sexually transmitted diseases (STDs). STDs, particularly gonorrhoea and chlamydia, can infect the reproductive tract and cause blocked Fallopian tubes or sperm-carrying ducts.

Seek prompt treatment for potential STDs. STDs cause more harm to fertility if they are untreated or not completely treated.

When selecting a birth control method, learn about its possible impact on future fertility and make that an important factor in your decision.

Make medical decisions with fertility in mind. Inquire about the impact of medications, including herbal supplements, on reproduction in men and women. If you develop a gynaecologic condition, such as a uterine fibroid, endometriosis, or abnormal Pap smear, ask which treatments are most likely to preserve your fertility.

Make fertility-enhancing lifestyle choices. In men, excess heat exposure can lower fertility. Cigarette smoking is associated with an abnormal semen count in men. In women, smoking can reduce fertility and raise the risk of miscarriage. Being underweight, losing weight rapidly, or exercising at an extreme level can impair fertility in both men and women. In women, obesity is also associated with lower fertility. For some couples, changing exercise habits or achieving a more healthful body weight leads to conception with no medical treatment.

Allow sufficient time to attempt conception. Many infertility factors do not make it impossible to conceive but lower the chance with each cycle. This lengthens the amount of time conception is likely to take. If you do not try to become pregnant until late in your reproductive years, or if you count on conceiving within a short time period, you are more likely to be unsuccessful and to assume you need medical help – even if you might be capable, given enough time, of conceiving without treatment.

A: Some treatments correct factors that cause infertility. If they work, the infertility should be reversed and a couple should be able to achieve one or more pregnancies. In contrast, other therapies are used to establish pregnancy in a treatment cycle without permanently correcting the underlying problem.

In some cases, medication can improve or correct an underlying medical condition that makes it difficult to conceive. Women with endometriosis, cervical infections, polycystic ovarian syndrome, or hormonal imbalances can be treated with medications, thus easing barriers to conception.

When a woman has blocked or damaged fallopian tubes, surgery to repair them is an example of treatment aimed at curing infertility. If it is successful (meaning the tube is both open and able to function normally), she should be able to conceive one or more times without further medical intervention. However, many experts believe that, for most women with blocked tubes, the chance of becoming pregnant is greater using in vitro fertilization(a technique to get around the problem) than surgery.

A: While you are trying to conceive, enjoy a healthful lifestyle. Take note of the strategies for preventing infertility (above) and consider how – such as smoking – you may be lowering your chances to conceive. Tell your doctor and pharmacist that you are trying to get pregnant. They can tell you whether any prescription or over-the-counter medications, supplements, or herbal remedies you or your partner use could be disturbing your fertility or be dangerous to use during early pregnancy. If so, ask what alternatives are available. Avoid douching or using vaginal lubricants.

Even a couple with no fertility problems have only about a one in four chance of conceiving during a single cycle. Maximize your chances by having sexual intercourse regularly during the fertile part of your cycle. If you have questions about when you are most likely to conceive, ask a health care professional. An ovulation predictor (available without a prescription) may help you determine when you ovulate so you can better time intercourse.

A: Most doctors advise you not to be concerned unless you have been trying to conceive – not using birth control and having regular intercourse around the time of ovulation – for at least a year.

Women with certain symptoms or previous medical conditions may wish to seek medical advice earlier. Some symptoms or prior conditions make fertility problems more likely, and others may indicate a medical condition that needs treatment for other reasons. Seek medical advice if:

• You have lots of pain during your menstrual period or during intercourse.
• You have an abnormal menstrual cycle (less than 21 or more than 35 days from the first day of one cycle to the first day of the next).
• You are troubled by acne or excess facial or body hair.
• You have had pelvic inflammatory disease (PID), an infection in the reproductive organs, usually the Fallopian tubes.
• You have had surgery on your reproductive organs, such as a cone biopsy of the cervix.
• You have had more than one miscarriage.
• Your partner has an abnormal sperm analysis.

A: An infertility work-up will involve tests to determine how well each of the systems involved in conception is working.

• EGG PRODUCTION: To determine if and when you are ovulating (producing and releasing a mature egg during the menstrual cycle), you may be asked to chart your basal body temperature. You will take your temperature before getting out of bed each morning. A slight, sustained rise in temperature is an indirect indication that ovulation has occurred. You may also be asked to use an ovulation predictor kit at home. Your doctor may check various hormone levels on specific days in your menstrual cycle, or monitor your body’s response to a dose of fertility medications.
• SPERM PRODUCTION: A semen specimen will be analyzed for the number of sperm, their shape and movement. If the results are abnormal, a man may be examined by a urologist or tested for hormonal abnormalities or infection.
• FALLOPIAN TUBES: To see whether the Fallopian tubes are open, an X-ray (called a hysterosalpingogram or HSG) may be taken while dye is injected into the uterus and tubes. Alternatively, a doctor might inject a salt-water solution and view the uterus and tubes using ultrasound (called a sonohysterogram). The tubes can also be observed during a surgical procedure.
• CERVIX: To determine whether sperm are able to swim through the cervix, a sample of cervical mucus is examined after intercourse. If this post-coital test is abnormal, other tests may be ordered to find out why. Doctors disagree about the usefulness of this test, and many couples conceive despite poor results on a post-coital test.
• UTERUS: The shape of the uterus is shown in an HSG. It can also be seen through a telescope-like device (hysteroscope) inserted through the vagina and cervix. An endometrial biopsy samples the uterine lining in the last half of the cycle to see if it is prepared for an embryo to implant. The thickness of the lining can also be measured using ultrasound.

A: Almost always. Both male and female factors can contribute to a couple’s infertility. For efficiency, diagnostic testing may focus first on tests that are less invasive (such as a semen analysis) or those that may confirm a suspected problem (such as a test for blocked Fallopian tubes if a woman has had a pelvic infection).

A: Experts often suggest seeing a specialist if you:

• Have endometriosis or damaged tubes.
• Are considering pelvic surgery for any reason.
• Have had two or more miscarriages.
• Have irregular menstrual cycles or another reason to believe you do not ovulate regularly.
• Have an abnormal semen analysis.
• Are a woman age 35 years or older.
• Have had a pelvic infection.
• Have not conceived in two years despite normal test results.