what Is Infertility?
Infertility is the inability of a couple to achieve a pregnancy in spite of frequent intercourse after a period of at least 12 months (the duration is less in certain circumstances where there are already identified unfavourable circumstances). Up to 25% of couples in Nigeria have challenges getting pregnant. Infertility may be due to a single or multiple cause(s) in either the female or male partner, or a combination of both.
For a pregnancy to occur, the woman releases an egg from either ovary every month, which is called ovulation. This released egg travels towards the Fallopian tube. The end of the tube is shaped like the fringes of a dress. These fringes continually move in a wave like manner, to pull the egg into the tube, from where it begins to travel towards the uterus. At the end of the tube, just before it enters the uterus, it is met by a healthy sperm. The sperm and the egg fuse together in a process called fertilization, and an embryo is formed. The embryo then continues the journey into the uterus and attaches to the uterine wall, in a process called implantation. Once implantation has occurred, the body starts to release more hormones that will aid in the growth of the baby, and the woman will discover that she is pregnant.
Anything that causes an interruption at any point in this process can cause infertility.
Causes of Infertility
Impaired sperm production – Sperm are produced in the testicles which are located inside the scrotum. Some conditions which can disrupt the production of normal sperm include:
- Undescended testes: The testis is not inside the scrotum, but is located higher up in the pelvis or abdomen
- Varicocele: Abnormal enlargement of veins in the testes
- Raised scrotal temperature: Can be caused by long distance driving, tight underwear
Impaired sperm transport – Some conditions can prevent sperm from being moved out of the testes and these include obstruction or malformation of the tube for transporting the sperm (vas deferens), blockage of the tube after a vasectomy (a method of permanent male contraception where the vas deferens is cut and tied off)
Impaired ejaculation – Where there is a problem with the release of semen during intercourse. This includes:
- Premature ejaculation: Release of semen too early
- Retrograde ejaculation: The semen flows backwards and into the bladder instead of out through the penis
- Anejaculation: Ejaculation does not occur
Impaired sperm function – This can be caused by a number of factors which include exposure to alcohol, smoking, marijuana, or steroids. Also medical conditions like diabetes, and exposure to chemotherapy or radiation treatments.
- Impaired production of eggs – Factors that can cause this include age related decline, premature ovarian failure, endometriosis or medical conditions like diabetes
- Disorders of ovulation – These are caused by abnormalities in the production of hormones, and common causes include Polycystic Ovarian Snyndrome (PCOS), hyperprolactinaemia, thyroid problems, adrenal problems, stress, being underweight or overweight, and certain medications
- Dysfunction of the Fallopian tubes – The tubes can become damaged by anything that causes it to be inflamed or scarred. Common causes include Pelvic Inflammatory Disease (PID, usually a consequence of a sexually transmitted infection) and adhesions (scar tissue) caused by endometriosis or previous surgery inside the uterus or the abdomen. Also, fibroids can cause a blocked tube if it is lying across the tube.
- Implantation problems – These are problems with the structure of the uterus or cervix which make it difficult for the fertilized egg to be implanted on the lining of the uterus. They include: fibroids, endometrial polyps, adenomyosis, and intrauterine adhesions
In up to 20% of cases, no definite cause can be found in either the man or the woman for infertility, when all tests done show normal results. This is termed as unexplained fertility. Making an accurate diagnosis of the underlying issue usually involves a series of investigations, which might be time consuming. For the woman, the tests may need to be done at specific times of the menstrual cycle. You will need to be mentally and emotionally prepared for this, and try to adjust your schedule as much as possible, so that there aren’t too many interruptions to your daily routine. While there are a number of tests that can be done, the specific tests you will have done and their sequence will depend on your individual case, and the decision will be made after your doctor has seen you and you both have come to an agreement.
- Seminal Fluid Analysis (SFA): This is a test of the semen, to determine whether the sperm and fluid are healthy. The number of sperm (count), movement (motility), normal forms (morphology), live forms (vitality), total volume, acidity, and presence of an infection are checked.
- Hormonal tests: These are occasionally done to check the level of testosterone and other hormones in the body.
- Ultrasound scan: This is done to examine the uterus and the ovaries and can be used to pick up things like fibroids, polycystic ovaries, adhesions, and in some cases, endometriosis
- Hormonal tests: These are blood tests that are done to measure the amount of specific hormones in the body to check for deficiency, excess, or imbalance. Some of them are done on specific days of the cycle in order to make an accurate assessment. Some of the hormones tested for include LH, FSH, Prolactin, Progesterone, AMH, Thyroid hormones, and Testosterone. This is sufficient to make diagnoses of PCOS, Hyperprolactinaemia, Ovarian Failure, Hyper- or Hypo- thyroidism, anovulation.
- Hysterosalpingography: It is commonly called a HSG and is a radiological test that is done to determine whether or not the tubes are patent. A dye in inserted into the uterus through the vagina, after which a series of X-rays are taken of the pelvic area. Demonstrating spillage of the dye through the tubes confirms that they are patent. A HSG can also show intrauterine adhesions, and determine the way a fibroid affects the uterine cavity.
- Magnetic Resonance Imaging (MRI): This is a very sensitive imaging technique which is more accurate than a conventional ultrasound scan. An MRI of the abdomen and pelvis can be used to make a more specific diagnosis of some identified problems like fibroids (shows the numbers, size, and location), endometriosis (shows the extent and stage), and adenomyosis (shows the size and location). It also helps in determining what kind of surgical treatment can be used for treatment.
- Hysteroscopy: Hysteroscopy is a method of visualizing the inside of the womb with a special tiny camera called a hysteroscope, which is fitted with a light source and passed from the vagina, through the cervix, and into the womb. The images are magnified and projected on a screen for the doctor to see and make assessments. It is used to identify any abnormality on the inside of the uterine cavity, like fibroids, polyps, and intrauterine adhesions (scar tissue). It is also used as a method of treating these issues.
- Laparoscopy: Laparoscopy is a type of surgical procedure in which the inside of the abdomen and pelvis is accessed by laparoscopic instruments, which include a laparoscope – a thin telescope fitted with a light source and a camera. They are passed into the abdomen through small cuts on the skin (about 1-2 cm long), and the images are then magnified and projected on a screen for the doctor to see. Laparoscopy can be used to check the patency of the tubes, confirm endometriosis, abdominal adhesions (scar tissue), polycystic ovaries, and fibroids. It can also be used to treat these conditions.
The results of the investigations done will be explained to you, and a treatment plan will be outlined, depending on what is found. Sometimes, all that is necessary is for you to monitor your menstrual cycle and determine when you usually ovulate, so that you can have timed intercourse.
Treatment options include:
- Ovulation induction and follicular tracking: This is used to address infertility that is caused by PCOS. Medications (tablets or injections) are given to stimulate the ovaries to ovulate (i.e to release an egg). After this, the ovaries are scanned regularly to monitor the growth of the follicle (the small sac on the ovary that contains the egg), and to confirm when ovulation occurs, so that sexual intercourse can be timed.
- Surgical treatment: You might require a surgery to treat problems like uterine fibroids, polyps, intrauterine and abdominal adhesions, and endometriosis. This can be done by hysteroscopy, laparoscopy, or laparotomy (abdominal surgery).
- Medical treatment: In some cases, issues like hyperprolactinaemia, and endometriosis can be managed with the use of some tablets and injections.
- Assisted Reproduction: This is the use of specialized medical procedures to bring about a pregnancy, when a couple cannot achieve this on their own. It includes the following:
- Intrauterine insemination (IUI): This is a process where the man’s sperm is collected and treated, after which it is directly inserted into the uterus when it has been confirmed that the woman has ovulated. It can be done in cases of disorders of ejaculation or poor sperm motility in the male, and tubal factors in the female. It can be done with a natural cycle, or together with ovulation induction.
- In Vitro Fertilization (IVF): In an IVF cycle, the man’s sperm and the woman’s eggs are collected and placed together under special conditions in a laboratory, to allow the sperm fertilize the eggs. The fertilized eggs (embryos) are then assessed and one or two with the highest quality are put back into the uterus for implantation to occur. Usually, the woman is placed on medications that will cause her to ovulate and produce a number of eggs that can be used. After the embryos are put back in the uterus, she will also be on some medications to aid implantation and growth of the embryo. This cycle takes a number of weeks and involves taking medications for a long time. IVF has helped numerous couples with infertility, and thousands of babies are born every year through this method. However, it doesn’t always work, and it is possible to have an unsuccessful try or tries before it does work.
- IVF with Intra Cytoplasmic Sperm Injection (ICSI): In this process, when the sperm and eggs are placed together, the sperm is injected directly into the egg in order to improve the chances of fertilization occurring. This is used in cases where there is a problem with the sperm.
- Gamete donation: Couples who have an issue with the production of sperm or eggs (for example in older women with reduced ovarian reserve) that cannot be treated have the option of using donor sperm or donor eggs for the IVF process, after which the resulting embryo is put into the woman’s uterus. She will be placed on medications to aid implantation and growth of the embryo.
- Surrogacy: In cases where there is a problem with the uterus that cannot be treated with surgery or medications, an option is to have an IVF process done (either with the use of the woman’s own eggs if they are suitable, or with the use of donor eggs or sperm), and put the resulting embryo into the uterus of another woman, who is called the surrogate mother. If the pregnancy is successful, the baby is carried to term and at delivery, the intending couple take their baby, whom they will have to formally adopt.
Using the best techniques science has, our fertility specialists at our sister organization, Bloom Fertility Clinic in Ikeja, Lagos, Nigeria are able and ready to assist you on the journey in fulfilling your dream.
We provide assisted reproductive treatments like IVF, IUI, ICSI, Cryopreservation – Egg Freezing, embryo freezing etc, fertility assessment for both couples and individuals and many more.
Bloom Fertility Clinic is committed to the successful evaluation and treatment of infertility as well as to the emotional well-being of couples and individuals on that journey.
For further inquiry on assisted reproductive techniques, please visit www.bloomfertilityclinic.com
If you would like to find out about fertility or have fertility concerns, book an appointment with us.