Infertility

Infertility is defined as the inability to conceive after a year of regular, unprotected sexual intercourse. It can be classified as primary or secondary. Primary infertility refers to couples who have never had a child, while secondary infertility refers to those who have had a pregnancy but are unable to conceive again.

To achieve pregnancy, couples should have intercourse during the woman's fertile days, which are a few days before and during ovulation. Since pinpointing the exact day of ovulation can be challenging, daily intercourse during the fertile period is recommended to maximize the chances of conception. If pregnancy has not been achieved after a year of frequent intercourse without contraception, the couple should seek evaluation. Sometimes, it is beneficial to seek help even before the one-year mark, especially as a woman's fertility starts to decline at age 30 and decreases significantly after age 40. Men's fertility also declines, but more gradually, with some remaining fertile into their 60s or 70s.

Evaluation may be initiated sooner if:

• A woman has irregular menstrual cycles, indicating infrequent or irregular ovulation.
• A woman has a history of three or more miscarriages (or if the man had a partner with three or more miscarriages).
• A partner had an infection affecting fertility (e.g., pelvic inflammatory disease, sexually transmitted diseases, or prostate infection).
• A partner is suspected of having fertility issues (e.g., previous unsuccessful attempts to conceive in another relationship).

Causes of Infertility

Infertility can be caused by:

• Ovulation disorders (20%)
• Cervical issues (5%)
• Uterine issues (5%)
• Fallopian tube issues (20%)
• Male factors (30%)
• Unexplained causes (20%)

The main cause of male infertility is low sperm quality, which can involve:

• Oligospermia (low sperm count)
• Azoospermia (no or very little sperm production)
• Abnormal motility (asthenospermia)
• Abnormal sperm morphology
• Sperm abnormalities (either larger or smaller than normal)
• Increased white blood cells in sperm (Leukocytospermia)
• Abnormal coagulation

Lifestyle and daily habits can affect sperm quality. Alcohol, drugs (including marijuana and nicotine), and environmental toxins (e.g., pesticides) can reduce sperm quality. Abnormal sperm production may be congenital or result from medical conditions like mumps, sexually transmitted diseases, testicular injury, or tumors. Inability to ejaculate can also cause infertility and may be due to factors like diabetes, certain medications, prostate or urethral surgery, or erectile dysfunction.

The main cause of female infertility is ovulation disorders, where ovulation does not occur or occurs infrequently. This can be marked by irregular menstrual cycles (oligomenorrhea) or absence of periods (amenorrhea). Lifestyle, stress, diet, and exercise can affect hormonal balance. Female infertility can also result from fallopian tube obstruction, caused by adhesions from pelvic inflammation, endometriosis, or ectopic pregnancy.

What Exams Need to Be Performed?

To assess male infertility, a semen sample is analyzed under a microscope. For female infertility, a complete history and clinical examination are essential. Common tests include:

• Ultrasound: The initial step in assessing fertility, detecting diseases of the cervix, uterus, fallopian tubes, or ovaries. Advanced 3D/4D ultrasound can assess the endometrial cavity more accurately.
• Hysterosalpingography (HyCoSy or HyFoSy): Uses contrast material to visualize the uterus and fallopian tubes, identifying whether the fallopian tubes are open. HyCoSy is less painful and has no radiation.
• Laparoscopy: A small incision is made near the belly button to insert a telescope-like instrument detecting conditions inside the abdomen or pelvis.
• Endometrial Biopsy: Removes small tissue samples from the uterine lining for microscopic examination to exclude conditions that negatively impact fertility.

Treatment

Based on test results, appropriate treatments are recommended. For women, common treatments induce ovulation using clomiphene citrate, gonadotropins, and GnRH analogues.

Assisted Reproduction Methods

Artificial insemination involves placing sperm in the woman's uterus using a flexible tube. In Vitro Fertilization (IVF) fertilizes the egg by the sperm in a laboratory.

• Freezing Eggs and/or Embryos: Eggs are harvested, frozen unfertilized, and stored for later use.
• IVF with a Donor Egg: Used when the ovaries are malfunctioning, have been removed, or if there is a genetic abnormality.
• Gamete Intrafallopian Transfer (GIFT): Eggs are collected from the ovary and placed into the fallopian tube along with sperm, where fertilization may occur naturally.
• Intracytoplasmic Sperm Injection (ICSI): A single sperm is injected directly into an egg to achieve fertilization, used when sperm count or motility is very low.

About two-thirds of pregnancies achieved through assisted reproduction are single pregnancies, with most of the remaining being twins.