Causes of Infertility

Definition of Infertility

There is no standard definition for Infertility. But most often, if you are under 35 years of age and have not conceived after a regular and contraceptive free intercourse for a year, you are generally considered eligible for treatment by an Infertility Specialist. Over the age of 35, the waiting period is usually six months.

Before you read any further, you should know that Fertility problems are nobody’s fault. It is a medical condition affecting almost one in ten couples so you are not alone.

There are many good reads about Infertility and it’s causes across the web so we assume that you have read most of those. Our idea here is to present the data in a format that is easy to understand. We do not to wish overwhelm you with medical terminologies and concepts, sometimes ignorance is a bliss.

Following chart shows the gender bifurcation of the infertility causes. Men and Women equally contribute to the Infertility Causes and for a larger percentage of time the clinical diagnosis of Infertility cannot be made and hence the reasons are termed as ‘Unexplained’. We know it is frustrating but not everything can be explained.

InfertilityCauses

Causes of Infertility

Female Infertility Causes

If we drill down the Infertility causes by gender, then the following chart shows the common causes that slows down conception in women:

Female Infertility Causes

Causes of Female Infertility

Types of Ovulatory Dysfunction

 

Polycystic Ovarian Syndrome

DefinitionDefined as a combination of menstrual problems (Scanty, infrequent, delayed or at times absence of periods), weight gain, infertility and a rise in the male hormone levels in the body. Also associated with an ultrasound image of ovary with excessive number of small follicles

 

Statistics

 

Common disorder affecting about 20 % of the females visiting a fertility clinic.  Incidence on the rise due to lifestyle changes and obesity.
Common Symptoms1.    Menstrual Irregularity: Scanty, infrequent, delayed or at times absence of menses.

2.    Obesity

3.    Infertility

4.    Excessive hair growth

 

CausesThought to be both inherited as well as affected by lifestyle.
DiagnosisClinical and by Ultrasound. Hormone tests rarely required.
TreatmentLifestyle changes (Exercise and Weight Loss)

Induction of Ovulation, Follicular Monitoring, IUI

If ovulation does not occur with oral medicines, injections (Gonadotropins) may be required. In severe cases which do not respond to medicines, Laparoscopic Surgery is recommended.

If Ovarian Hyperstimulation occurs,  IUI can be converted into IVF

Likelihood of Pregnancy Post TreatmentVery Good.  Ovarian Stimulation more effective if life style changes are incorporated concurrently.

 

Stress directly affects your body and your Fertility. Here’s how!

PCOS-Stress

 

Endometriosis

DefinitionWhen the cells from the uterine lining start growing  outside the uterus, for example in the peritoneum, fallopian tubes, ovaries, bladder or intestines
Statistics

 

10% of Normal Female Population and up to 20% of Females with Infertility face this problem
Common SymptomsRecurring Pelvic Pain

Mild to severe cramping on both sides of Pelvis

Extremely painful cramping during menses (dysmenorrhea)

Painful intercourse (dyspareunia )

Urgency in urination, frequent urination (dysuria)

 

 

CausesGenetic Predisposition

Environmental Toxins like Dioxins

Aging

DiagnosisSymptoms

Laparoscopy is considered the Gold standard for diagnosing endometriosis

TreatmentLaparoscopic treatment (cauterization) of endometriotic spots

Ovarian Stimulation and Intrauterine Insemination (IUI) : Cost Effective and appropriate first line of treatment as it increases the chances of pregnancy per cycle

IVF may required in severe cases where endometriotic adhesions are dense.

Likelihood of Pregnancy Post TreatmentVery Good Pregnancy rates after treatment.

Early treatment and conception recommended as the disease is progressive in nature. Pregnancy itself is a good cure for the disease and therefore most of the symptoms like painful periods, pelvic pain etc are relieved after pregnancy.

Diminishing Ovarian Reserve

DefinitionWhen the number of eggs in the ovary are reduced. In most cases leads to premature loss of ovarian function (premature ovarian failure at less than 40 years of age).
Statistics

 

Accounts for 20% of all cases of female infertility.

With an increase in age the number of eggs decreases. The rate of fall accelerates after the age of 32-33 leading to sterility at a mean age of 41.

Common SymptomsOnly extreme degree of diminished ovarian reserve is symptomatic. This stage is characterized be peri-menopausal symptoms like hot flushes, night sweats, mood swings, painful intercourse due to vaginal dryness, exhaustion and similar symptoms
CausesGenetic/Familial: Daughters have menopause earlier if mothers have had early menopause

Autoimmune: Some autoimmune diseases are linked with loss of ovarian function

Chemo or Radiotherapy induced: Used as a part of anti-cancer treatment

DiagnosisMenstrual History: Irregular cycles

Ultra Sound: Small ovaries, Reduced antral follicle count

Hormones: Raised FSH, LH. Low AMH and Estradiol

TreatmentAttain pregnancy as soon as possible, may require ovarian stimulation with IUI to increase chances of conception per cycle. Supplementation  with DHEA therapy is recommended for expected poor responders
Likelihood of Pregnancy Post TreatmentVery good till treatment is carried out in a timely manner. Once ovarian reserve is depleted, IVF with oocyte donation gives good results.

Poor Egg Quality

DefinitionMicroscopic evaluation of egg showing abnormal appearance indicating low fertilization ability
Statistics

 

Increasing as age of attainment of pregnancy is on the rise. No exact figures available.
Common SymptomsInfertility

Repeated implantation failures

Premature menopause

CausesAge: Commonest cause of deterioration of quality of egg.

Local pathology like Endometriosis, Pelvic Inflammatory Disease (PID), Genital Tuberculosis

Systemic Disorders: Autoimmune Disorders, Endocrinological abnormalities like High Prolactin levels

DiagnosisMenstrual History: Irregular cycles

Ultra Sound: Small ovaries, Reduced antral follicle count, unruptured follicles noted during follicular monitoring

Hormones: Raised FSH, LH. Low AMH and Estradiol, High Prolactin

During IVF after oocyte retrieval, when the eggs are viewed under magnification

TreatmentSupplement with Anti oxidants, DHEA. Correct reversible causes like like High Prolactin levels. If uncorrectable cause or If oocyte quality remains poor inspite of treatment, oocyte donation with IVF
Likelihood of Pregnancy Post TreatmentVery Good either with own eggs or if own eggs have lost fertilization ability, with donor eggs and IVF

Ovulation  Abnormalities

DefinitionAny disorder in the process of release of egg form the ovary. Can range from irregular ovulation (Oligo-ovulation) to complete absence of ovulation (An-ovulation)
Statistics

 

Accounts for 35% of causes of infertility amongst women
Common SymptomsDelayed or absent menstrual cycles
CausesHormonal Derangements (Thyroid, Prolactin)

Age: increased ovulation abnormalities as age increases

DiagnosisMenstrual History: Irregular, Infrequent or absent menses

Serum Progesterone : At least one week before expected day of menses, less than 3ng/ml best hormonal marker for anovulation

Ovulation prediction kits or LH kits: Failure of positive test

Endometrial Biopsy: Rarely done nowadays for ovulation prediction as it is an invasive procedure. When done, absence of secretory changes in endometrium indicate anovulation

Ultrasonography: Best indicator nowadays. Indicates absence of any growing follicle when monitored from day 9 of menses onwards.

TreatmentInduction of ovulation with medicines or injections after correction of pre-existing abnormality if any.
Likelihood of Pregnancy Post TreatmentVery good if induction of ovulation sucesssful

Fallopian Tube Blockage

DefinitionBlockage of the Fallopian Tube or severe damage to the inner lining of the Fallopian tube making it nonfunctional.
Statistics

 

Accounts for 30 % of all cases of female infertility.
Common SymptomsRarely symptomatic. Mostly presents as inability to conceive.  In some cases can cause lower abdominal pain if associated with pelvic inflammatory disease (PID)

 

 

Causes
  1. Infections: Genital Tuberculosis, Chlamydia, Sexually Transmitted Diseases
  2. Structural: Surgical procedures, endometriosis, tubal ligation etc.

 

DiagnosisEndometrial Biopsy for detection of Tuberculosis, Hystero Salpingo Graphy (HSG),  Sono Salpingo Graphy (SSG), Laparoscopy (Gold Standard)
TreatmentLaparoscopic release of adhesions, restoring normal tube-ovary relationship, Opening of fimbrial ends of the fallopian tube and similar endoscopic procedures. In some cases, laparoscopic correction may not be possible due to extent of damage to the tubes. In all such cases, IVF is the treatment of choice.
Likelihood of Pregnancy Post If minor adhesions are corrected surgically, chances of spontaneous conception are very good. If significant loss of tubal function exists, Good Pregnancy rates with IVF.

Male Infertility

In approximately 40 percent of infertile couples, the male partner is the sole cause and in 20 percent a contributing cause, of infertility. Despite the male factor being at least partly responsible in about 60 percent of infertile couples, infertility evaluations have traditionally focused on women, because women tend to seek Gynaecological care and because men often are reluctant to seek advice.

A variety of disorders ranging from hormonal disturbances to physical problems, to psychological problems can cause male infertility. Although many treatment options are now available, in many cases treatment will not work.

In many instances, male infertility is caused by testicular damage resulting in an inability of the testicle to produce sperm. Once damaged, the testicle will not usually regain its sperm-making capabilities; this aspect of male infertility is analogous to menopause (though not natural like menopause) for women and cannot usually be treated.

Despite medicine’s limited ability to treat male infertility, many successful treatment options are available today for its many causes. Besides testicular damage, the main causes of male infertility are low sperm production and poor sperm quality.

Causes of Male Infertility

Male factor infertility refers to the failure of a couple to achieve conception due to problems specifically related to the man’s sperm, seminal fluid, or reproductive organs. A number of things can affect sperm count, ability to move (motility) or ability to fertilize the egg. The most common causes of male infertility include:

  • Abnormal sperm production or function due to various problems, such as undescended or torsion testicles, varicocoele, genetic defects such as Klinefelter’s Syndrome, hormonal disorders (which may also disturb libido and cause impotence) such as hyperprolactinemia, hypothyroidism, congenital adrenal hyperplasia, hypogonadotropic hypopituitarism and panhypopituitarism or infections such as mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and syphilis.
  • Problems with the delivery of sperm due to sexual problems, such as erectile disfunction, premature ejaculation, ejaculatory incompetence or painful intercourse (dyspareunia); health issues, such as retrograde ejaculation; certain genetic diseases, such as cystic fibrosis; or structural problems, such as blockage of the part of the testicle that contains sperm (epididymis). Scarring from tuberculosis or some STDs like gonorrhea and chlamydia may block the epididymis or tubes.
  • General health and lifestyle issues, such as poor nutrition, obesity, stress, or use of alcohol, tobacco and drugs.
  • Overexposure to certain environmental hazards and toxins, such as pesticides, lead, paint, radiation, radioactive substances, mercury, benzene, boron, and heavy metals.
  • Ageing Male. Men older than age 40 may be less fertile than younger men.

Test’s for Evaluating Male Infertility

Because the end results of the many disparate problems that cause male infertility are low sperm count, abnormal sperm shape, and poor sperm motility, additional tests besides a semen analysis are required to pinpoint the cause of the infertility. For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman’s vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.

  • General physical examination. This includes examination of your genitals and questions concerning your medical history, illnesses and disabilities, medications, and sexual habits.
  • Semen analysis. This is a very important test for the male partner. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes your semen specimen for quantity, colour, and presence of infections or blood. Additional specialized sperm functional tests such as post-coital/cervical mucus test or sperm penetration assay may be done, if semen analysis is normal.
  • Hormone testing. A blood test to determine the level of testosterone and other male hormones is common.
  • Doppler evaluation of the testis and Transrectal Ultrasound. Doppler/Ultrasound can help your doctor look for evidence of conditions such as retrograde ejaculation and ejaculatory duct obstruction.

Treatment of infertility involves comprehensive evaluation of both male and female to find an ideal solution to the couple’s problem.

Treatment of Male Infertility

Treatment of male infertility depends on the cause, how long you’ve been infertile, your age and your partner’s age, and many personal preferences. Some causes of male infertility can’t be corrected. However, a woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.

Simple lifestyle changes, like abstaining from alcohol, tobacco, and illicit drugs can improve male fertility. A healthy diet, sufficient (not excessive) exercise, and proper amounts of vitamin B12, vitamin C, and zinc also improve fertility.

General sexual problems

Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is primarily with medication or behavioural approaches, though mechanical and surgical treatment is sometimes effective. Artificial insemination with an ejaculate can be used to overcome infertility.

Treatment for Low Sperm Count

  • Hormonal treatment if needed – usually in 5% of men
  • Surgical treatment of varicocele
  • Ejaculatory duct incisions
  • Medical treatment
  • Sperm concentration methods
  • Electro Ejaculation

 

Treatment for No Sperm Count

  • If due to blockage – Microsurgical Bypass operations
  • Micro Epididymal Sperm Aspiration (MESA)
  • Bilateral testicular biopsies

 

Donor Insemination

Therapeutic donor insemination (TDI) option can be considered for many causes of male infertility as mentioned below:

  • Irreversible Azoospermia
  • Severe Oligospermia
  • Poor motility and abnormal morphology of sperm
  • Known genetic disorders in the male e.g. Huntington’s disease, hemophilia etc.
  • Males with non-correctable ejaculatory dysfunction secondary to trauma, surgery or drugs, neurological disease, spinal chord injuries, etc.
  • Reproductive option after radiation or chemotherapy
  • Severely Rh-sensitized Rh-negative women with an Rh-positive partner