- How common is infertility across the worldwide?
The World Health Organization (WHO) estimates that approximately 8-10% of couples experience some form of infertility problem. Globally, at any point of time about 50-80 million people suffer from infertility. However, the incidence of infertility may vary from region to region. In France, 18% of couples of childbearing age said that they had difficulties in conceiving.
- What are the conditions leading to infertility?
Ovulatory disorders and anatomical abnormalities such as damaged fallopian tubes are the most common culprits. Other less frequent causes include, for example, endometriosis, tuberculosis and hyperprolactinemia. Male factors can be divided into three main categories: Sperm production disorders affecting the quality and/or the quantity of sperm; anatomical obstructions; and other factors such as immunological disorders. Immunological or endocrine problems and failure of the testes to respond to the hormonal stimulation triggering sperm production account for a third of all cases of male infertility. However, in a great number of cases of male infertility is due to inadequate spermatogenesis (sperm production) or sperm defects, the origin of the problem still remains unexplained.
- Is it always the female who is responsible for the infertility?
Not necessarily . The incidence of infertility in men and women is almost equal. Infertility is exclusively a female problem in 30-40% of the cases and exclusively a male problem in 10-30% of the cases. Problems common to both partners are diagnosed in 15-30% of infertile couples. In spite of thorough medical investigations, the causes of the fertility problem remain unexplained in only a minority of infertile couples (5-10%).
- I and my husband do not have any health issues, my periods are fairly regular and normal and we both have a good sex life. In spite of it I haven’t been able to conceive what could possibly be wrong.
The cause for your infertility can be determined only after you undergo tests to find out if your husband's sperm count is normal; if your fallopian tubes and uterus are normal; and if you are producing eggs. It is only after undergoing these tests will your doctor be able to tell you why you are not conceiving. Though testing does cause considerable anxiety, it's far better to intelligently identify the problem so that we can look for the best solution.
- What kind of treatment would we need to undergo?
The options offered to couples depend on the type of infertility that has been diagnosed. The vast majority of female patients are successfully treated with the administration of drugs such as clomiphene citrate, or gonadotrophins. Wherever needed surgery can also be a means to repair damage to the reproductive organs, such as those caused by endometriosis and infectious diseases. Women with Irreparably damaged tubes which are beyond surgical repair can be by passed in IVF to help you conceive. The various options for male infertility also include the administration of drugs, surgery and assisted reproductive technologies, such as intracytoplasmic sperm injection (ICSI). Drug therapy and surgery have proved very successful for specific types of male infertility. However, in a great number of cases, the reason why men have fertility problems remains unexplained and the treatment methods applied are empirical. Some patients nevertheless require more complex medical intervention. Assisted reproductive technologies (ART) includes a whole gamut of treatment options designed to overcome barriers to natural fertilization such as IVF, ICSI, IMSI .In-vitro fertilization (IVF), has been around for more than 25 years. ICSI is a relatively recent innovation been a used since 1991. Overall, the estimated number of infertile patients currently treated by ART is around 20%.
- How frequently do we need to have intercourse inorder to conceive?
A properly timed sexual intercourse substantially increases the possibility of a spontaneous pregnancy. This means that sexual intercourse, or coitus, has to be taken place around the time of ovulation, which is the most fertile period of a woman. To detect the approximate time of ovulation a temperature curve of several menstrual cycles can be made. The woman takes her body temperature each morning before getting out of bed, starting on the first day of the menstruation until the start of a new period. The body temperature rises around 0.5 degree Celsius after the ovulation. This is mostly about 14 days after the first day of the period and when no pregnancy occurs the temperature drops to normal again; with pregnancy the temperature stays high. However these methods are not so accurate. One can also use urine or saliva tests to detect the ovulation. The time of ovulation can sometimes vary a few days each month, even in a regular menstrual cycle. If the circumstances are favorable the, sperm can live inside the women for a few days at the same time sperm quality can decrease with high and frequent sexual activity. Therefore it is best to have intercourse 3-4 days before the expected ovulation and every other day until 2-3 days after the expected ovulation with no necessity for higher frequency. When tests are used to detect ovulation it is advised to have sexual intercourse on the day of a positive test.
- Does every infertile couple need Intrauterine Insemination?
No. Intra Uterine Insemination (IUI) involves directly introducing in to the uterus of the processed semen. The main thing to remember is that at least one of the fallopian tubes of the woman should be healthy and patent. It is a technique used for couples with fertility problems based on specific causes. These causes are:
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Cervical hostility: Wherein the cervix is not permeable for semen as demonstrated by the Post Coital Test.
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Idiopathic subfertility: No cause has been found for the inability to conceive.
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Male subfertility the sperm quality is decreased. Clinics use different ranges for sperm count in which they perform IUI.
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Sperm Antibodies:Presence of antibodies which inactivate the sperm.
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Inability for vaginal ejaculation with decreased sperm quality. For example in men with retrograde ejaculation or spinal cord injury. IUI can be performed either in a spontaneous ovulatory cycle (cervical hostility) or in a cycle with ovarian stimulating hormones (idiopathic subfertility and male subfertility/sperm antibodies). The stimulation is mostly done with clomiphene citrate or gonadotrophins.
- How do I know which is the best possible treatment for me to conceive?
A variety of procedures can be used to diagnose the cause of infertility in a couple; these range from simple blood tests to more complicated analytical methods. In any case, diagnosis is a crucial first step to determine the appropriate therapeutic path that should be followed. In addition to the cause itself, other factors, such as the age of the woman, or problems shared by both partners, might also influence the choice of treatment.
- Is it necessary for all patients seeking infertility treatment to undergo counseling?
The physician helps the infertile couple find the most appropriate therapeutic path to overcome barriers to conception, but, before a treatment is started, patients need to be aware of all its aspects, including its constraints. Beyond the medical expertise, infertile couples are also looking for counseling and support. From a psychological point of view, infertility is often a hard condition to cope with. During treatment and before a pregnancy is achieved, feelings of frustration or loss of control usually experienced by the infertile couple are likely to be exacerbated. Management of infertility includes both the physical and emotional care of the couple. Therefore, support from physicians, nurses and all people involved in treating the infertile couple is essential to help them cope with the various aspects of their condition. Offering counseling and contact with other infertile couples and patient associations can provide help outside the medical environment.
- How earliest can one conceive after starting the infertility treatment?
When talking of success rates for any type of infertility treatment, one should bear in mind that even for a normally fertile couple the average chance to conceive after having regular unprotected intercourse is around 25% during each menstrual cycle. It is estimated that 10% of normally fertile couples fail to conceive within their first year of attempt and 5% after two years. Comparable to normal fertility rates, effective treatments can be expected to have, on average, up to a 35-40%success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate; more than 80% of women suffering from such disorders are likely to conceive after several cycles of treatment with drugs such as clomiphene citrate or gonadotrophins.
- Would IVF guarantee a better possibility of conceiving?
Overall, success rates for IVF have steadily improved over the last ten years. Birth rates for IVF vary according to the expertise of the centers practicing this technique. However, centers in Europe have reported pregnancy rates after one cycle of IVF equal or superior to 25%. In 1993, the French IVF registry (FIVNAT) reported a pregnancy rate of 25.4% per embryo transfer on a total of 23,025 oocytes retrieved. Based on such results, after three to four cycles of IVF, a woman under 40 whose partner does not have any fertility problems could reasonably expect to give birth. The success rates may vary from one center to another, since they are influenced not only by the level of expertise of the medical team but also by the characteristics of the patients treated. A clinic treating a large number of women over 40 is likely to report lower success rates than a clinic having a majority of patients under 35.
- What factors are indicative of a more fruitful outcome of the infertility treatment?
In any type of infertility treatment, important factors need to be taken into account when referring to success rates. The age of the woman and the duration of the couple's infertility are likely to influence the success of treatment. In women, fecundity decreases as age increases, particularly after 40 years of age. When the woman is being treated, her chances of conceiving can be lessened if her partner also has infertility problems (e.g. poor quality sperm).
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Though every clinic aims to succeed in helping every couple that hopes to conceive, in reality, this cannot be guaranteed. In our practice, we work with couples to explore the causes of their infertility and to outline all possible treatment options. By empowering couples to explore these options and participate as a partner in the decision-making process, we believe each and every couple is helped.
- How long would the IVF or ICSI treatment go on?
It takes approximately six to eight weeks for each complete IVF or ICSI cycle. First, the normal menstruation cycle of the woman is down regulated by injection or nasal application of specific hormones each day. This part of the cycle can vary from a few days to several weeks. When the ovaries have become inactive, shown on ultrasound control and laboratory findings, the stimulation of the ovaries start by muscular or subcutaneous injections of hormones. The mean stimulation period is 10-12 days, depending on the response of the ovaries. The ovum pick up takes place within two days after stopping the stimulation. Now the real IVF or ICSI follows in the laboratory. When fertilisation occurs, embryos are transferred into the uterus after two to four days and drugs supporting the uterus are given. After approximately 15 days a pregnancy test will show whether the IVF treatment has been successful or not.
- What are the treatment options for a woman who cannot produce any eggs?
The answer to this would be a pregnancy through egg donation. In this procedure an anonymous woman, who has been medically screened and tested, will function as an egg donor. This woman will have an IVF stimulation and ovum pick up. After the ovum pick up the collected eggs will be fertilised with sperm of the partner of the recipient woman i.e. donor acceptor. The embryo's are then transferred in uterus of the donor acceptor. If a pregnancy occurs, then the donor acceptor and her partner will have a child which is only biologically half their own.
- Which part of the cycle is the most fertile?
The fertile period is the time during which having sex could lead to a pregnancy. This is the 4-6 days prior to ovulation (release of a mature egg from the ovary). Women normally ovulate 14 days prior to the date of the next menstrual period. Usually the fertile period is one week before and after the probable date of ovulation, given your periods are regular.
- Why do the fallopian tubes get damaged?
Initially In-Vitro Fertilisation (IVF) was meant d for patients facing infertility due to damaged fallopian tubes. Subsequently indications to perform IVF were broadened, for example unexplained infertility and male infertility. Nowadays tubal damage still accounts for a large number of all IVF treatments. The main cause is abdominal infection. For the tubes this is mostly due to sexually transmitted diseases (for example Chlamydia or gonorrhea) but complicated appendicitis or Pelvic Inflammatory Disease (PID) can also cause damaged tubes. Other causes are abdominal operations (gynecological operations, cesarean section, sterilisation or other) and internal diseases like Crohn's disease. Affected patients can have fertility problems and are at risk for having a pregnancy located in the tubes (ectopic or tubal pregnancy).
- What is endometriosis? How seriously does endometriosis affect fertility?
Endometriosis refers to presence of tissue histological identical to endometrium (the inner lining of the uterine wall) outside the uterine cavity. Usually, endometriosis is confined to the pelvic and lower abdominal cavity; however, it has occasionally been reported to be in other areas, as well. Endometriosis is one of the most common problems that gynaecologists currently face. It is one of the most complex and least understood diseases in our field and, despite many theories; we still do not have a clear understanding of the cause or of its relationship to infertility. Since this disorder is primarily a human disease and rare in other animal species, accumulation of the facts has been slow. Although endometriosis has been considered a pathological or separate disease entity, it may not be a disease at all. It may actually be the clinical manifestation of a more basic underlying disorder, such as a basic chemical or physiological abnormality that affects the tubal motility or immune system which could be responsible for the initiation or progression of endometriosis in patients with retrograde menstrual flow. By the same token, endometriosis may not be the cause of infertility, but the result of it. Further technological developments may be necessary in order for us to fully understand this problem.
- What is polycystic ovary syndrome or PCOS?
PCOS affects about 4-6% of all women it is essentially an ovulation disorder. Several factors contribute to the disease. At this moment researchers think that the cause of the disease is genetic. The major features of this syndrome are irregular or no menstruation, hirsutism and acne due to high levels of male hormones, obesity (40-50%), high insulin levels with risk for developing diabetes and large polycystic ovaries shown on ultrasound. Women with PCOS usually present at fertility clinics for counseling. To increase fecundity the treatment possibilities are mostly focused on regulation of the menstrual cycle. For this, several drugs are used (clomiphene citrate, bromocriptine, gonadotrophins) and weight loss is strongly advised. In many cases the cycle will be ovulatory and regulated by these treatments. Furthermore at this moment it is being investigated whether electrocoagulation of the large ovaries can give (long-term) regulation of the cycles.
- Can the uterine or tubal defects be corrected?
Reproductive surgery is a subspecialty that treats anatomical abnormalities interfering with normal reproductive function. Advanced reproductive surgery requires meticulous surgical technique for optimal results, including rapid patient recovery and avoiding the need for routine hospitalisation. Reproductive surgeons treat tubal obstruction, endometriosis, uterine fibroids, scarring of the ovaries or other pelvic structures resulting from pelvic inflammatory disease (PID) in the female and testicular biopsy and surgical sperm extraction in the male as well as other abnormalities.
- Is laproscopy required for every patient?
The laparoscope allows visual inspection of the pelvic organs through a very tiny incision. Abnormalities that lead to infertility can be treated surgically through additional small incisions to remove scar tissue, laser, coagulate, or excise endometriosis, and repair tubes blocked at the fimbrial end. Many types of female reproductive surgery can be performed laparoscopically in the outpatient setting.
- If the male partner is unable to ejaculate is there any other alternative?
TESE (Testicular Sperm Extraction): refers to the surgical process of obtaining the Sperm directly from the testicles.
MESA (Microsurgical Epididymal Sperm Aspiration): refers to the process of microscopic surgery used to retrieve the sperms from the ducts that convey them from the testicles. This is attempted in case there’s an obstruction to the duct (obstructive azoospermia).. TESE or MESA is a technique developed for patients with no sperm cells in their sperm due to an undeveloped or obstructed spermatic cord. The cause of obstruction can be a former sterilisation or an infection of the epididymis. When the testicles make no sperm cells at all, of course TESE or MESA is not possible. If sperm cells are obtained, an ICSI procedure (Intra Cytoplasmic Sperm Injection) will follow.
- Why is Progesterone used for IVF? Is any other kind of medication given during or after IVF?
Progesterone is required for the success of early pregnancy. In a natural cycle progesterone is made by the corpus luteum (CL). If the CL is removed during the first 5 weeks after conception, the pregnancy will miscarry. There are 2 reasons for giving extra progesterone after an IVF.
The first is that the CLs in IVF were all disturbed by the IVF needle during egg pick-up. The CLs start as follicles containing eggs. At the retrieval, the needle is placed inside the follicle, the egg is removed; and other cells may also be removed. The follicle is mostly fluid, but it also contains tons of cells that make up the follicle and surround the egg. These are called the granulosa cells; and these are the cells that convert to CL cells after ovulation. So if the needle removes some of these cells, as is usually the case, the CL would not work as well, and less progesterone is produced hence an external support is needed.
The second is to do with IVF medication. In a natural cycle, the hormone LH is secreted by the pituitary in small doses after ovulation, as this LH helps the CL to produce progesterone. However, during an IVF cycle, most women are given Lupride, Gonapeptyl or Ovurelix to suppress a premature LH surge at ovulation. In a natural cycle or IUI, surges are fine, they cause ovulation. In IVF, we need to time the retrieval to the hour, so that a surge at the wrong time does not ruin everything. So we give medicines to stop LH surge; but this means LH is no longer available to help the CL with progesterone production as well.
- Is cryopreservation a part of all the IVF procedures?
Cryopreservation means preserving in a frozen condition. The best known cryopreservation is of semen. This is mostly done in case of cancer of the testicles before treatment of the cancer. Furthermore cryopreserved semen is used in donor insemination. It is also possible to freeze fertilised eggs after IVF or ICSI. If there are some unutilized embryos after an IVF or ICSI procedure they can be frozen and transferred another time. In this way there is more chance on a pregnancy while only one IVF or ICSI cycle is performed. For human oocytes cryopreservation is much more difficult. Only in very few experiments this is done successfully. The attention of researchers now is on developing a way to freeze ovarian tissue and after thawing, to obtain the oocytes in it. This procedure is not yet fully refined but when it is it can offer great opportunities in the future.
- If the period is painful is that suggestive of infertility?
Painful periods do not affect fertility. In fact, for most patients, regular painful periods usually signal ovulatory cycles. However, progressively worsening pain during periods (especially when this is accompanied by pain during sex) may mean you have endometriosis which in turn may affect your fertility.
- Since I get periods after every 6 weeks or so would this be a cause for my infertility?
As long as the periods are regular, this means ovulation is occurring. Some normal women have menstrual cycle lengths of as long as 40 days. Of course, since they have fewer cycles every year, the number of times they are "fertile" in a year is decreased. Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30 day cycle).
- Are the sperms used as it is or do they undergo some processing?
Sperms are ejaculated in the seminal fluid during intercourse or masturbation. During assisted reproduction the sperms are extracted from the semen by a series of processes - centrifugation and washing, layering (to select the active sperm and leave the immotile or dead sperm behind) or selecting the best sperm by making them swim through a denser medium and using those that succeed. These lab procedures are refered to as sperm preparation
- Would the infertility treatment have any adverse effects on my health?
Along with their intended benefits, drugs used to treat infertility may on occasion cause side effects. In ovulation induction, close monitoring of follicular growth is crucial to ensuring successful treatment. Monitoring techniques (such as ultrasound scan and blood tests) and adequate use of treatment protocols help the physician to avoid ovarian hyperstimulation syndrome (OHSS) and minimize the risk of multiple pregnancy. Current treatment protocols have been designed in a way to reduce the risk of multiple births and OHSS though they are not completely avoidable.
- Are the local side effects of the injections used in the treatment very painful?
Common local side effects experienced by patients who receive gonadotrophins by intramuscular injection include skin redness, swelling and bruising. Pain and discomfort sometimes reported after intramuscular injections are now likely to be lessened with the availability of gonadotrophins produced by recombinant DNA - or genetic engineering - techniques which are administered by subcutaneous injection.
- Multiple births
Multiple births occur more frequently after infertility treatment than in the normal population. About 80% of pregnancies achieved following simple ovulation induction with gonadotrophins result in single births, the remaining 20% being multiple pregnancies, mostly twin pregnancies. New treatment regimens carefully adapted to the patient's response help to decrease the risk of a multiple pregnancy. After IVF, one pregnancy out of four is multiple (20% twin pregnancies and 3-4% triplets. In IVF centers, physicians now frequently choose to replace a maximum of two embryos after fertilization, to further reduce the chance of multiple births.
