WHAT IS INFERTILITY
IS INFERTILITY A COMMON PROBLEM ?
* Templeton A, Fraser C, Thompson B. Human Reproduction 1991;6(10):1391-1394.
IS INFERTLITY JUST A WOMAN'S PROBLEM ?
WHAT CAUSES INFERTILITY and RISKS FOR FERTILITY IN MALES ?
More than 45% of infertile couples coming to an infertility clinic are found to have male fertility as a cause of sub fertility. This means that the semen analysis is one of the most important tests conducted in the fertility evaluation. Most specialists agree that treatment of the female should not begin without the male evaluation.
Unlike women, whose fertility declines with age, men are capable of fathering a child until later in life. Age related male infertility is usually not an issue before age 55.
Causes range from ejaculatory to testicular failure; therefore the complete history and examination is mandatory when there is inability for producing an ejaculate or when semen parameters are showing a lower range. Most common cause is viral infection during childhood e.g. Mumps complications such as orchitis, varicocele, congenital absence of vas and many systemic diseases like diabetes.
Sperm are produced in the seminiferous tubules of the testicles under the influence of the hormone testosterone. The testicles are composed of these tubules and the epididymis, which stores and transports sperm.
Sperm travel from the epididymis to the vas deferens (small tubes), past the seminal vesicle and prostate where seminal fluid is added, and ultimately out through the urethra at ejaculation. This path must be free of obstructions.
The testicles are suspended in the scrotum which serves as a temperature regulating organ. When the testicular temperature is elevated, the scrotum expands increasing the distance of the testicles from the body thus lowering temperature. Conversely, when the temperature of the testicles drops, the scrotum contracts drawing them closer to the body.
Factors that tend to increase the testicular temperature, such as prolonged sitting in hot tubs, occupations such as (long distance truck driver where the scrotum cannot perform its cooling function), can lower sperm count. Sperm take approximately three months to mature so changes in habits that could affect sperm count are not immediately apparent.
The semen analysis involves evaluation of numerous sperm characteristics and is best conducted by a reproductive medicine laboratory. Most of these laboratories use the Kruger Strict Criteria; however, some still use the World Health Organization criteria.
We follow the WHO fifth edition criteria based on the work of doctors (TF Kruger and R Menkeveld) at the Tygerberg Hospital in South Africa.
We follow the WHO fifth edition criteria based on the work of doctors (TF Kruger and R Menkeveld)at the Tygerberg Hospital in South Africa.
- Semen volume – (the amount of fluid which makes up the semen) – at least 1.5 mL
- Sperm count- the number of sperm present in a standard volume – 15 million/ mL
- Motility- the percent of sperm moving when the semen is examined under the microscope. Normal is defined as ≥40% motile.
- Progression – the forward movement of sperm cells.
- Viability- the percentage of live sperm.
- Sperm morphology or shape- Normal is at least 4%
- Additional semen contents, such as white blood cells are an indication of infection. Less than 1m/mL white blood cells per high power field are considered normal.
One of the causes of male sub fertility can be a varicocele, which is the existence of varicose veins in the scrotum. These veins can cause abnormal circulation raising the temperature of the testicles and diminishing sperm production. A urologist if needed can perform a surgical procedure to remove the varicocele. A urologist can also sometimes successfully reverse a vasectomy depending on patient specific variables.
Various fertility medications, such as Clomid and recFSH, have been used to treat male infertility. Unfortunately, they are limited in usefulness and require extended therapy which can be extremely expensive.
Some health products boast that they can increase sperm quality and quantity; however, to date, no study has demonstrated a statistically significant advantage to using these “enhancers”.
When there is mild male infertility, intrauterine insemination (IUI) or artificial insemination is often the treatment of first choice. In IUI, the sperm are collected via masturbation; then washed and concentrated. The concentrated sample is placed directly into the uterus using a small catheter. Unprepared sperm must never be inserted directly into the uterus as very serious allergic reactions and severe uterine cramping can result.
In the past, men with moderate to severe male factors, had no hope of producing a genetically related child. Due to recent advances in in-vitro fertilization and Intracytoplasmic Sperm Injection (ICSI), a pregnancy can be produced even when very small numbers of sperm are present. A single sperm is inserted directly into the egg in the ICSI procedure.
This sperm can be collected from an ejaculate or, if the male has had a vasectomy, sperm can be aspirated directly from the male’s epididymis using PESA (percutaneous sperm aspiration). Sperm can be aspirated from the testicles using a fine needle Testicular Sperm Aspiration (TESA), or extracted surgically from the testes using TESE (Testicular sperm extraction, or Microsurgical Sperm Extraction (MESE). This means a pregnancy can be produced even if no ejaculate can be produced.
Fortunately, most sub fertile men can now be effectively treated though surgery or by using Assisted Reproductive Technologies.
Hypertension and drugs used for treatment of chronic diseases or chemotherapies decline the semen quality and quantity.
Recent data also emphasizes on the odd lifestyles of men; specially addictions of any kind (smoking shisha, alcohol, etc) are found to be more responsible for decline in fertility. Trauma to the spinal cord due to any reason, e.g. accident or cerebral disorders, epilepsy, complication of endocrinopathies and last but not the least- the genetic and chromosomal disorders are also responsible for the sub normal semen parameters. Sexually transmitted diseases and perineal skin infections can also lead to infertility.
WHAT CAUSES FEMALE INFERTILITY ?
Ovulatory disorders are common reasons of female sub fertility or delay in conception (30%. 70%) of these cases can be successfully treated medically by Clomiphene and aromatase inhibitors (Letrozole). The causes of failed ovulation can be categorized as follows:
(1) Hormonal Problems
Ovulation depends on hormonal balance so any imbalance affects the whole process of reproduction, following are the causes:
- Failure to produce mature eggs
In approximately 50% of the cases of anovulation, the ovaries do not produce normal follicles in which the eggs can mature. Ovulation is rare if the eggs are immature and the chance of fertilization becomes almost non-existent. Polycystic Ovary Syndrome, the most common disorder responsible for this problem, includes symptoms such as amenorrhea, hirsutism, anovulation and infertility. This syndrome is characterized by a reduced production of FSH, and normal or increased levels of LH, estrogen and testosterone. The current hypothesis is that the suppression of FSH associated with this condition causes only partial development of ovarian follicles, and follicular cysts can be detected in an ultrasound scan. The affected ovary often becomes surrounded with a smooth white capsule and is double its normal size. The increased level of estrogen raises the risk of breast cancer.
- Malfunction of the hypothalamus
The hypothalamus is the portion of the brain responsible for sending signals to the pituitary gland, which, in turn, sends hormonal stimuli to the ovaries in the form of FSH and LH to initiate egg maturation. If the hypothalamus fails to trigger and control this process, immature eggs will result. This is the cause of ovarian failure in 20% of cases.
- Malfunction of the pituitary gland
The pituitary’s responsibility lies in producing and secreting FSH and LH. The ovaries will be unable to ovulate properly if either too much or too little of these substances is produced. This can occur due to physical injury, a tumor or if there is a chemical imbalance in the pituitary.
(2) Scarred Ovaries
Physical damage to the ovaries may result in failed ovulation. For example, extensive, invasive, or multiple surgeries, for repeated ovarian cysts may cause the capsule of the ovary to become damaged or scarred, such that follicles cannot mature properly and ovulation does not occur. Infection may also have this impact.
(3) Premature Menopause
This cause represents a rare and as of yet unexplainable cause of anovulation. Some women cease menstruation and begin menopause before normal age. It is hypothesized that their natural supply of eggs has been depleted. The majority of cases occur in extremely athletic women with a long history of low body weight and extensive exercise. There is also a genetic possibility for this condition.
(4) Follicle Problems
Although, currently unexplained “un-ruptured follicle syndrome” occurs in women who produce a normal follicle, with an egg inside it every month, yet the follicle fails to rupture. The egg, therefore, remains inside the ovary and proper ovulation does not occur.
- www.resolve.org — National Infertility Association
- www.asrm.org — American Society for Reproductive Medicine
- www.urologyhealth.org — American Urological Association
- www.afafamilymatters.com — American Fertility Association
- www.ssmr.org — Society for the Study of Male Reproduction
- www.sart.org — Society for Assisted Reproductive Technology
- www.cdc.gov/ART/index.htm — Centers for Disease Control: Assisted Reproductive Technology Report