Infertility is a personal problem with lot of family and social implications. Because of that diagnosis and treatment of infertility has gained much importance. Increase in the number of infertility couples and their awareness regarding the treatment facilities have increased the number of patients attending the clinics. Increased age of marriage, voluntary infertility practiced by the upper class of patients, absentee husbands are the main contributory factors responsible for the decrease in fertility
Normal Fecundity (pregnancy expected per cycle in a healthy couple) in a cycle is only 15-20 %; hence the infertility investigation may be delayed up to one year. But in special situations like late marriages, or when there is a known problem in a couple, it is better to start investigation and treatment early.
In a normal female eggs are produced from the ovary in the middle of the menstrual cycle. Sperm produced during the sexual act at that time travel from the vagina through the cervix, uterine cavity and meets the egg to fertilize at the outer end of the tube. Embryo formed after fertilization travels through the tube in to the uterus and gets implanted in the uterine cavity and grows to a full term baby. Any thing that interferes with these normal physiological events can cause infertility, like
- Defective ovulation
- Problems with spermatozoa
- Problem with transport of gametes
- Defective implantation
- Sexual problems
- Unexplained infertility
Even though it was ignored for a long time single most important cause for infertility lies in the males. Either the sperms cannot be produced in sufficient amount, or if at all produced they are not normal. Even if normal they get blocked in male genital tract or male has some sexual problems, which interferes with ejaculation and deposition of sperms in to the vagina. In extreme cases where the sperm production is not possible for the male there is no treatment. Many other causes of male infertility can be treated medically or by various surgeries. When there is no response to these treatments advanced techniques known as IUI (Intrauterine Insemination), ICSI (Intracytoplasmic Sperm Injection) has helped many couples to parent a child
Ovulation problem is the second most important cause of infertility and most common cause of female infertility. 90% of the cases ovulation problem is due to policystic ovarian syndrome. Rarely it may be due to increase in hormones like prolactin or decrease in hormones like Thyroid, FSH and LH or abnormal levels of different hormones.
Typical pattern in the PCOS may present with a irregular or prolonged period, obesity and increased hair growth, multiple small cysts in the ovary in ultrasonography. Another group of patients may not have all the above features. Because PCOS is multi factorial origin the response to treatment also varies from patients toto patients.
Treatment options for PCO in infertility varies from ovulation induction, ovarian drilling or ART. From simple tablets to costly hormone injection or surgical treatment like laparoscopic surgery to assisted reproductive techniques like IVF / ICSI may be necessary in these group of patients. A small group of patients may not respond to any treatment at all. A woman with normal menstrual cycles should not be labeled as a case of anovulation problem.
Endometriosis: Is one of the common causes of infertility in females especially in our part of the world. In this disease uterine lining cells are found in sites other
Than uterus and there will be cyclical bleeding from these sites during menstruation. These blood cannot go out of the body, which may lead to sticking of these structures. This commonly occurs in ovaries, tubes and around the uterus, leading to painful menstruation. It also destroys the normal anatomy and affect normal ovulation.
Also it affects transport of ovum through tubes there by preventing fertilization. Many times diagnosis is possible by ultrasound, but sometimes can be diagnosed only by laparoscopy. The best treatment now available is laparoscopic surgery, but again few cases may end up in IVF, ICSI treatment.
Different causes like pelvic infection may produce tubal block and adhesions. Isolated tubal block in the proximal part of tube and adhesions can be treated with laparoscopy or may need laparotomy, otherwise they will conceive only with IVF/ICSI
Hydrosalpinx is a condition in which there is collection of fluid inside the tube resulting in tubal block. If there is bilateral hydrosalpinx only 10-20% of patient will get normal conception after surgery. Remaining patients may need IVF treatment. Tubal block secondary to tuberculosis has only IVF as treatment option.
Sexual problem is an important cause of infertility. But fortunately most of the cases can be treated with Psychological counselling.
Diagnostic Procedures: Dramatic developments in the field of science have helped to diagnosis and treatment of infertility in a more scientific manner. Semen analysis is the integral part of infertility investigation. Interpretation will be sensible only when it is done by a reliable lab. In addition to count and motility, morphological staining may be done as a routine part of semen analysis.
Endocrine studies has helped is to diagnosis most of anovulatory infertility.Transvaginal ultrasound can diagnose most of problems related with infertility. And it also helps in the treatment monitoring. Perhaps that is the only non-invasive weapon by which we can judge the quality of endometrium. Also it can diagnose the tubo ovavarian pathology.
Introduction of Hysterolaproscopy has revolutionized the treatment of infertility. It is considered as a gold standard for diagnosis of certain infertility conditions. It is the last option to treat most of the surgical problems related to infertility.
Treatment Options: Intra Uterine Insemination (IUI) is a very simple treatment, which can increase the fertility rates in a sub fertile couple. Here concentrated good quality sperms, separated from the toxic contents are deposited into the upper part of uterus, at the time of ovulation in a stimulated cycle. Unexplained infertility, vaginal hostility, poor sperm count are the accepted indication for IUI. But unless it is done with all precautions, by itself it can cause pelvic infection and tubal block
Test Tube Baby Treatment (IVF& ICSI) - Birth of Lousie Brown in 1978 by Assisted reproductive Technique (Infertility treatment in which both the egg and sperm are handled outside the body) was an important landmark in the treatment of infertility.
It was done on a patient with tubal block, which could not be corrected by surgery. Till then there was no treatment for such a condition. Later this was done for indications like unexplained infertility, pelvic adhesions, endometriosis, PCOS and moderate OAT.
But unfortunately there was no treatment for very bad OAT, obstructive azoospermia and in may cases of fertilization problem. Another landmark in infertility treatment was the birth of a baby born in 1992 with ICSI (Intra Cytoplasmic Sperm Injection). Here a single sperm was injected into egg resulting in fertilization and embryo formation. In ICSI only one sperm was sufficient to produce an embryo.
Most of the male problem could be corrected by this method. Compared to the conventional IVF, fertilization failure is minimal and it could give better pregnancy rates. Now most of the couples for IVF treatment are treated by ICSI.
Advances in infertility techniques: Even with all modern treatments ultimate pregnancy rates with ART is about 30%. Many advanced techniques have come up in the field of ART to improve the success rate. Many of these are available in India.
Laser: This technique has improved the ICSI procedure by immobilization of sperm, zona drilling of embryo. Zona drilling facilitates Assisted Hatching, which improves the pregnancy in elderly females and in repeatedly failed cases.
Blastocyst Culture: In this technique if there are facilities like triple gas incubators and special medias embryos can be grown upto blastocyst stage outside body before putting back into uterus. Again this may help to improve pregnancy rates, reduce maternal and foetal morbidity and mortality during treatment.
PIGD (Pre Implantation Genetic Diagnosis): This is the most recent development in ART treatment. The idea of this treatment is to identify the normal embryos before it is transferred to mother. It has the potential to identify and exclude the embryos with diseases like Down syndrome early in the treatment. Once this treatment is fully established, it can improve the success of treatment in many patients.
Conclusion: Any couple looking for infertility treatment, it is better they have a basic knowledge about infertility and available investigative and treatment techniques. This will help the couples to approach the treatment more confidently.
Dr. FESSY LOUIS.T
AMRITA Fertility Centre
M. G. Road, Kochi.