Definition and Overview

Infertility is a medical term that refers to a couple’s inability to become pregnant after at least one year of contraceptive-free vaginal intercourse. For women, infertility also means failure to maintain or carry a pregnancy to live birth. The disorder is very common and according to the World Health Organisation (WHO), it affects one in every four couples in developing countries.

Infertility can affect both men and women. One-third of infertility cases are caused by female reproductive issues, one-third by male reproductive issues, and one-third by either both male and female reproductive issues or unknown causes, which means that doctors are unable to identify the reasons why pregnancy is not occurring.

Female infertility can be caused by physical problems, age, environmental or lifestyle factors, or hormone problems. In men, the common causes are lower sperm count, poor sperm health, and vas deferens blockage. Although the condition is sometimes difficult to diagnose, there are now many available treatments that have helped many reproductively challenged couples to conceive a child. These include assisted reproductive technology (ART) that helps achieve pregnancy through in vitro fertilisation (IVF) and surrogacy, among many others.

There are two types of infertility:

  • Primary infertility, or when a woman who has never conceived a child has difficulty getting pregnant

  • Secondary infertility, or when a woman who has had successful pregnancies in the past is having a difficulty conceiving again

Causes of Condition

The causes of female infertility can be genetic or acquired. These include:

  • Ovulation disorders - These disorders can be caused by hypothalamic pituitary failure, polycystic ovary syndrome, hyperprolactinaemic amenorrhoea, and ovarian failure. Ovulation disorders are responsible for approximately 25% of all infertility cases.

  • Blocked fallopian tubes - Accounting to 20% of female infertility cases, this usually occurs due to infection, uterine fibroids, endometriosis, and ectopic pregnancy, among others.

  • Poor egg health - Factors that can impact the health of the ovaries and eggs are poor lifestyle choices (such as sedentary lifestyle and poor diet), serious medical conditions (such as cancer), hormonal imbalance, and autoimmune disorders.

  • Antisperm antibody - A woman’s body can develop an allergic reaction to her partner’s semen. When this happens, their immune system releases sperm antibodies, which can either damage or kill the sperm. This is called immunologic infertility.

In some cases, doctors are unable to identify the causes of the condition (unexplained infertility) even after extensive infertility workup.

Certain factors that can increase a woman's risk of infertility are:

  • Age - Women’s fertility starts to decline when they reach their 30s. At 40, their chances of getting pregnant in any given month are just 5%.

  • Smoking - Smoking damages many organs in the body including the cervix and the fallopian tubes. It also increases the risk of ectopic pregnancy and miscarriage.

  • Weight - Being significantly under or overweight has an impact on normal ovulation.

Key Symptoms

The main symptom of female infertility is not getting pregnant after one year of regular unprotected sex. Other symptoms include:

  • Changes in menstrual cycle

  • Skin changes, such as severe acne

  • Changes is sex drive

  • Pain during sex

  • Thinning hair

  • Painful menstruation

Who to See and Types of Treatments Available

Female fertility is commonly diagnosed through the following:

  • Review of the patient’s complete medical history

  • Thorough physical exam

  • Blood and urine tests to check hormone levels

  • Pap smear, to check the health of the cervix

  • Ultrasound, to look for fibroids and cysts in the ovaries and uterus

  • Ovarian reserve testing, which determines the quality and quantity of eggs available for ovulation

  • Genetic testing, which determines if infertility is caused by a genetic defect

Female infertility treatment depends on many factors including the patient’s age, whether it is primary or secondary fertility, the exact cause of the condition, and the patient’s resources and preferences. Because infertility is a complex disorder, treatment requires significant financial, time, and psychological commitments.

Treatment options include:

Fertility drugs - Women who are unable to get pregnant due to ovulation disorders are prescribed with fertility drugs. One of the commonly used is clomiphene, an oestrogen-blocking drug that triggers the pituitary gland and hypothalamus to release gonadotropin-releasing hormones, luteinizing hormones, and follicle-stimulating hormones. Women who are taking the drug are expected to start ovulating seven days after the last dose was taken. If the patient has not become pregnant after six months of taking the drug, doctors will prescribe different medications or another form of treatment.

Surgery - If the disorder is caused by abnormalities, such as endometrial polyps or fibroids in the uterine cavity, patients are treated with laparoscopic surgical procedures, which may include:

  • Tuboplasty – Repair of the fallopian tubes

  • Ovarian cystectomy – Removal of ovarian cysts

  • Myomectomy – Fibroid removal

  • Laparoscopic surgery for endometriosis

  • Laparoscopic ovarian drilling, which triggers ovulation in women who have polycystic ovary syndrome

Intrauterine insemination (IUI) - An artificial insemination method that involves placing sperm inside a woman’s uterus. Its goal is to maximise the number of sperm that reach the fallopian tubes to increase the chances of fertilisation.

Assisted reproductive technology (ART) - Due to the growing number of couples who are having problems conceiving, various innovative treatments have been introduced. These treatments are provided by a multidisciplinary team of doctors commonly composed of physicians, embryologists, nurses, dietitian, fertility specialists, and lab technicians, among others. Some of the most common ART techniques in use today include the following:

  • In vitro fertilisation (IVF) – In this procedure, mature eggs are collected from the ovaries and fertilised with sperm in a lab. The fertilised eggs are then implanted in the uterus. IVF is a complex series of procedures, and it takes about two weeks to complete one IVF cycle.

  • Intracytoplasmic sperm injection (ICSI) – A type of IVF procedure in which sperm is injected into an egg.

  • Donor eggs – This option is considered when there are severe problems with the woman’s eggs.

  • Surrogacy – Recommended to women who are not healthy enough to get pregnant or have a dysfunctional uterus. In this option, the couple’s embryo is placed in the uterus of their chosen gestational carrier.

References:

  • Frequently asked questions. Gynecologic problems FAQ138. Evaluating infertility. American College of Obstetricians and Gynecologists. http://www.acog.org/~/media/For%20Patients/faq136.pdf?dmc=1&ts=20130521T1027034009.

  • Infertility: Frequently asked questions. National Women's Health Information Center. http://www.womenshealth.gov/publications/our-publications/fact-sheet/infertility.pdf.

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