What is infertility?

Infertility is defined as the inability to conceive during a whole year of sexual intercourse without contraception and can be defined as primary or secondary. Primary infertility is when a couple never had a child. Secondary infertility is failure to conceive following a pregnancy. In both primary and secondary infertility, the evaluation and treatment, as well as the causes of infertility, are the same. In order to achieve pregnancy, the couple must have had sexual intercourse during the fertile days of the woman’s menstrual cycle, i.e., few days before and during ovulation. As it is difficult to determine the exact day of ovulation, sexual intercourse on a daily basis is highly recommended during the fertile period to maximize the chances of conception. If after a year of frequent sexual intercourse without the use of contraceptive measures, pregnancy has not yet been achieved, the couple should be evaluated by a health professional. Sometimes it is useful to seek help for fertility problems even before the end of the one-year period. At the age of 30 a woman’s fertility starts to decline. It has also been observed that the older you get, the greater the chance of miscarriage. However, the reproductive potential decreases considerably after the age of 40. It is not the same for men and although the reduction in sperm production begins at the age of 25, some remain fertile until they are 60 or 70 years old. Evaluation may be initiated sooner in couples if:

• A woman experiences an irregular menstrual cycle, which indicates thatovulation occurs infrequently or irregularly. In this case conception is almost impossible to be achieved without medical support.
• A woman has a history of three or more miscarriages (or if the man previously had a partner who had three or more miscarriages).
• Partner had an infection that affected fertility, (i.e., pelvic inflammatory disease, sexually transmitted diseases or prostate infection).
• Partner is suspected of having fertility problems (they unsuccessfully tried to conceive in a previous relationship).

Causes of infertility

Any disruption in the complex conception process can lead to infertility. To achieve fertilization, the sperm must reach the fallopian tubes. Fertilization normally takes place in the fallopian tube once the egg has been released from the ovary. During fertilization, the sperm and egg unite in one of the fallopian tubes to form a zygote. Then the zygote travels down the fallopian tube, where it becomes a morula. Once it reaches the uterus, the morula becomes a blastocyst. The blastocyst then burrows into the uterine lining, called endometrium. Infertility can be caused by disorders of ovulation in 20%, in pathology of the cervix in 5%, in pathology of the uterus in 5%, in pathology of the fallopian tubes in 20%, in disorders in men in 30% and at unexplained causes (unexplained or idiopathic infertility) in 20% of cases. The main cause of male infertility is the low sperm quality. Sperm abnormalities may be related to abnormal sperm count such as:

• oligospermia (very few sperm are produced)
• azoospermia: (no sperm or very little is produced)
• abnormal motility (asthenospermia)
• abnormal sperm morphology
• sperm abnormalities ( small, large),
• the detection of increased white blood cells in the sperm (leukocytospermia),
• and abnormal coagulation.

Lifestyle and certain daily habits can affect the number and quality of a man’s sperm. Alcohol and drugs, including marijuana and nicotine can temporarily reduce sperm quality. Environmental toxins including pesticides and other chemicals, can also be responsible for infertility. The abnormal sperm production may exist from birth or be caused later as a result of a serious medical illness, including mumps and certain sexually transmitted diseases, a serious testicular injury or tumour growth. Inability to ejaculate is also a possible cause of infertility and can be caused by many factors, such as diabetes, antihypertensive drugs, prostate or urethral surgery, or erectile dysfunction. The main causative factor of female infertility comes from ovulation disorders (i.e., the total number of abnormalities due to which ovulation does not occur or occurs at infrequently). If ovulation does not occur then no eggs are available to achieve fertilization. Ovulation disorders are marked by irregular menstrual cycles (oligomenorrhea, sparse menstruation) or amenorrhea (complete absence of period). Other factors, such as lifestyle, stress, diet, or exercise, can affect a woman’s hormonal balance. Rarely, a hormonal disorder can result from a serious medical problem such as a pituitary or hypothalamic tumour, infections, Turner syndrome, etc. Female infertility can also occur due to obstruction of the fallopian tubes (and therefore the eggs cannot reach the uterus). Obstruction is caused by the formation of adhesions as a consequence of pelvic inflammation, endometriosis (abnormal presence of endometrial cells in other organs of the pelvis), ectopic pregnancy (when the fertilized egg is implanted in the fallopian tube and begins to grow there). Adhesions increase the chance of infertility because, depending on their location, they can impede the mobility of the fallopian tubes and / or cause a distortion between the fallopian tube and the ovary. A medical evaluation can determine if any of the above causes could have led to infertility or it is due to other causal factors. If the medical and sexual history does not reveal the problem, such as the absence of ovulation or not meeting on fertile days, special tests may have to be performed.

What (kind of) exams need to be performed?

The assessment of male infertility focuses on the examination of the quality and quantity of sperm (sperm count). In the laboratory, a semen sample is first examined under a microscope to check the number of sperm, their shape and movement. Further tests may be needed to diagnose possible infection, hormonal disorders, or other problems. In the context of the evaluation of the infertile woman, a complete history should be taken, a clinical examination should be performed as well as a check of the aetiology of infertility using laboratory, ultrasound and invasive examinations. For the woman the first step in assessing infertility is to examine her menstrual cycle (is ovulation performed every month?). This can be done by using an ovulation test. The test for ovulation and the determination of the cycle can be done by the gynaecologist based on simple blood tests (in which the levels of specific hormones are checked) or with an ultrasound examination of the ovaries. The most common tests performed in the context of the investigation of female infertility are:

• Ultrasound is the first step in assessing a patient’s fertility. Diseases of the cervix, uterus, fallopian tubes or ovaries can be detected. At the same time, the endometrium and ovaries can be assessed for their contribution to infertility. With a 3D/4D ultrasound we can assess both the endometrial cavity and areas of the female genital system that were indistinguishable from the simple 2D. Now we can even perform a salpingography painlessly in just a few minutes.
• Hysterosalpingography/salpingography, more specifically ultrasound-tubing – HyCoSy or HyFoSy: a special test in which, using the appropriate contrast material, the uterus and fallopian tubes are “visualized”. This identifies whether the fallopian tubes are patent. HyCoSy has minimal pain and no radiation compared to classic salpingography. Partners are welcome during and after the examination of the patient. More information on HyCoSy can be found at gynecology-ultrasound.gr or at https://www.salpingografia.com/ or on our Facebook page. It would be our pleasure to provide more information in person or by telephone.
• Laparoscopy is performed by inserting a telescope-like surgical instrument through a small incision to help diagnose a wide range of conditions that develop inside the abdomen or pelvis. examine. During laparoscopy, the surgeon makes a small cut (incision) of around 1 to 1.5cm (0.4 to 0.6 inches), usually near your belly button. The woman is under general anaesthesia.
• Endometrial biopsyis a medical procedure in which a small piece of tissue from the lining of the uterus (the endometrium) is removed for examination under a microscope. In this way we exclude benign or malignant conditions that have a negative impact on fertility.

Treatment

Depending on the results of the tests performed as part of the evaluation, appropriate treatments are recommended to address the problem. In 80-90% of cases, medication or surgery may be chosen as a method of treatment. The most common treatment for women is to induce ovulation to produce eggs. The induction of ovulation is achieved by ovulatory drugs. The most widely used drugs are clomiphene citrate, gonadotropins and GnRH analogues. The benefits of each medication as well as the possible side effects should be discussed with your doctor. About 10-20% of pregnancies that occur after ovulation are multiple pregnancies. Other drugs that can be used to induce ovulation are dopaminergic substances, such as bromocriptine and cabergoline. These drugs are prescribed when the ovarian function has been affected by high prolactin levels. Surgery is the treatment of choice when damage to the ovaries, fallopian tubes, or uterus must be repaired in order for fertility to improve. In men, the infertility problem that is usually treated surgically is the obstruction of the seminal vesicles. Damage to the seminal vesicle can be caused by an infection, a sexually transmitted disease or a vasectomy (ligation of the seminal vesicles leading to infertility). Other important tools in the treatment of infertility are artificial insemination and various methods of assisted reproduction.

Assisted Reproduction Methods

In some cases, a couple may not be able to conceive because of problems that make it impossible to ejaculate during sex, or because sperm cannot penetrate the vaginal or cervical mucus, or for other reasons. By artificial insemination, the sperm is placed in the woman’s uterus, using a hollow, flexible tube. It is worth mentioning the In Vitro Fertilization (IVF) technique during which the egg is fertilized by the sperm in the laboratory. It was initially applied in cases of women with infertility due to tubal aetiology. Later it was applied in cases of unexplained infertility, male infertility, endometriosis and infertility due to anovulation. Initially, medication is administered to induce ovulation and produce many eggs. Once the eggs are mature, they are collected using a fine needle then isolated directly in the biological laboratory and placed in a special test tube or in special plates together with the sperm, collected at the same time as the eggs, to be fertilized. The dishes containing the eggs are then placed into an incubator, so that the environmental conditions surrounding the eggs can be well controlled with regard to light, oxygen and carbon dioxide concentrations, as well as the pH and temperature. In case of fertilization, the fertilized egg is then transferred to the uterus. If the woman does not become pregnant, the procedure can be repeated in the next cycle. Other methods of assisted reproduction, which are based on similar techniques, are:

• Freezing eggs and/or embryos: Eggs harvested from your ovaries are frozen unfertilized and stored for later use. A frozen egg can be thawed, combined with sperm in a lab and implanted in the uterus
• IVF with a donor egg: This method is used in case the ovaries are malfunctioning or have been removed or if the woman has a genetic abnormality that will be inherited to her offspring. The procedure is exactly the same as in vitro fertilization with the difference that the eggs have been obtained from a donor.

About two-thirds of pregnancies achieved by some method of assisted reproduction are single pregnancies. Of the remaining one-third, almost all resulting pregnancies are twins (only 6% of pregnancies are triplets or multiples).