Infertility

Infertility

The basics of infertility

Struggling to have a baby is something many may experience in their lives. Men and women alike experience it, so much so that male infertility is as common as female infertility. Doctors refer to infertility as not being able to fall pregnant after one year of actively trying to conceive through regular sexual intercourse without using birth control. Women over 35 are often diagnosed as suffering from infertility if they cannot get pregnant after six months of trying to conceive through regular sexual intercourse.

The issue with infertility or subfertility (reduced fertility) is that you may not be aware of the condition until you attempt to conceive. Roughly one in six couples in the US will struggle with infertility, with one in four battling with the condition in developing countries. Globally, 9% of the population battle with infertility. 

It is important to know that being infertile does not mean you are sterile. Whereas sterility means it is impossible for a couple to have children, infertility, although seemingly negative when one is presented with the news, still holds some hope because while you may be unable to conceive a child for whatever reason, you may still be able to in the future through medical intervention or self-help.

Bear in mind, complex medical intervention is not always required and it is a common misconception amongst those struggling to conceive that IVF (in vitro fertilisation) is their only option. This, however, is not always the case. The treatment for infertility will depend on the cause of the condition. In some couples, one partner may be suffering from thyroid issues such as an underactive (hypothyroidism) or overactive thyroid (hyperthyroidism), this may have a direct impact on fertility as the hormones produced and regulated by the thyroid gland have an influence on ovulation and fertility. Cases such as these can be easily treated with oral medication. It is advised that you see a reproductive specialist to assist in correcting any abnormalities before more complex intervention is considered.

Infertility may be the result of various factors in either a male or female that interfere with conception. Thanks to advances in modern medicine, there are a number of possible solutions that are able to significantly improve your chances of falling pregnant.

The following article explores the causes, symptoms, treatment and risks of infertility in men and women, separating the two sexes in order to clearly differentiate between them. It is vital to note that this information is intended to serve only as a guideline and not as a professional opinion. It is always recommended that you consult with your doctor for that and any assistance and advice that you require.

Infertility in men

What causes fertility problems in men?

The most common cause of infertility in men is typically due to an issue with sperm, which may include a low sperm count, low sperm mobility, abnormally formed sperm or blocked sperm ducts.

Men are constantly producing new sperm, therefore the process of production is an ongoing one. However, it takes between two and three months for sperm to mature, become motile (able to move) and be able to fertilise an egg. Unlike women, a man’s age is not an indicator of his chances of conceiving, therefore, his age is not an indicator of his ‘biological clock’. The conditions under which the sperm is created will determine whether the sperm is healthy or not. Therefore, maintaining a healthy lifestyle is vital in ensuring the production of healthy sperm.

Male infertility causes are further explained as follows:

  • Issues with delivery of sperm – this includes sexual issues such as premature ejaculation as well as genetic diseases such as cystic fibrosis, or structural issues like a blockage in the testicle and damage to the reproductive organs. Retrograde ejaculation is another issue with the delivery of sperm, and refers to when the sperm, which is typically ejaculated through the urethra, is redirected to the bladder. 
  • Abnormal production of sperm – this is due to undescended testicles, genetic defects, infections such as chlamydia, mumps, HIV or gonorrhoea, or heart problems such as diabetes. Another issue can be varicocele, this is a disorder where the veins in the testes become enlarged, affecting the quality of the sperm.
  • Damage to the testes due to cancer and cancer treatment – chemotherapy and radiation can affect sperm production resulting in very low levels of sperm.
  • Pesticides, chemicals, radiation and other overexposure to environmental factors – this can include smoking cigarettes, excessive alcohol intake, taking certain medications such as specific antibiotics and steroids can also affect fertility. Recurrent exposure to heat can raise your body temperature and also affect sperm production, this includes long, hot baths, saunas, steam rooms and hot tubs (jacuzzies). 
  • Chronic cannabis use - The chronic use of cannabis (more than three times a week) has a direct impact on sperm, particularly its physical appearance (morphology). However, the topic of the effects of cannabis on sperm quality has been a largely debated one. Despite alternate claims, there is concrete evidence to support the fact that chronic cannabis use may have a significant impact on the quality of sperm.
  • Certain treatments for hair loss  - Certain treatments known as 5-alpha-reductase inhibitors, contain an enzyme that is found naturally in the adrenal glands and is responsible for converting testosterone to DHT (dihydrotestosterone), which is a sex hormone. These drugs can have an effect on sperm production.

How is infertility diagnosed in men?

Your doctor is likely to begin with a physical examination and then discuss your sexual and medical history. After this, if there is no evident cause for the issue, he/she may conduct additional tests.

In order for a male to be fertile, the testicles must produce adequate amounts of healthy sperm that is effectively ejaculated into the vagina during intercourse and in turn, travels to the egg inside the woman’s fallopian tube where conception occurs.

Specific fertility tests may include:

  • Semen analysis –your doctor may ask for semen specimens which are obtained through masturbation or interrupted sexual intercourse which involves the ejaculation of semen into a specialised condom that does not contain any spermicide (a type of contraceptive liquid that kills sperm).  The ejaculate from this condom is then carefully transferred to a clear container that is provided and sent to the lab for analysis. It is important that no lubricants or spermicides are used during this process as this will distort the semen results.
    It is also possible to test the urine for sperm, which can sometimes be present in infertility cases due to retrograde ejaculation.
  • Genetic testing – this is done in order to find out if there is a genetic defect causing infertility.
  • Hormonal testing – this is often done through a blood test to determine testosterone levels.
  • Imaging – is sometimes used in certain situations and is obtained through an MRI, bone mineral density scan, scrotal or transrectal ultrasound or when a vasography (X-ray of the vas deferens) is performed.
  • Testicular biopsy – this is sometimes conducted to identify any abnormalities that may be contributing to infertility as well as to retrieve sperm to use in reproductive techniques that are medically assisted, such as IVF (In Vitro Fertilization).
  • Other speciality testing – can be used to determine and evaluate the sperm quality and also pick up on DNA abnormalities.

Symptoms of infertility in men

The symptoms of infertility in men can be very vague and can even go unnoticed until a man tries to have a child with a woman.

The symptoms are dependent on the cause of infertility and can include:

  • Loss of sexual desire
  • Loss of hair and other changes in the growth of hair
  • A lump, pain or swelling in the testicles
  • Issues with ejaculation and erections
  • Small and firm testicles

Treatment of infertility in men

Treatment for men is dependent on the cause of infertility, the man’s age and his partner’s age (men over 40 have less probability of having a baby than men who are younger), the man’s personal preferences for treatment, and the duration of time that he has been infertile. Treatments can range from oral tablets and injectables to microsurgery.

Fertility treatments can often require a significant amount of time, effort and financial investment.

That being said, the following are treatment options for male infertility:

  • Changing lifestyle factors –improving behavioural and lifestyle factors such as stopping harmful medications and substances, ensuring that the time of intercourse lines up with a woman’s ovulation cycle, establishing healthy lifestyle habits through a nutritional diet and exercise as well as optimising the factors that can improve the chances for fertility.  If your semen analysis results are poor, then it is advised that you stop smoking and drinking alcohol in order to improve your fertility and the chances of conception.
  • Surgery – in certain conditions, surgery may be required. This is often needed when a sperm blockage needs to be reversed or surgery is required to repair a varicocele (caused by enlarged veins in the scrotum). Medication – there are a number of medications that are able to improve a man’s sperm count by increasing testicular functionality which includes sperm quality and production.
  • Sperm retrieval – this is needed when ejaculation is an issue or when no sperm is found in the fluid ejaculated. These techniques are also used when sperm counts are low or abnormal.

Infertility in women

What causes fertility problems in women?

Infertility in women is often due to age and the associated decline in the ovarian reserve.

The ovarian reserve refers to how many eggs a woman has left at any one point in time.  Women are ultimately born with a set number of eggs and lose multiple eggs each month through ovulation and the menstruation. Therefore, a woman’s age although not an optimal predictor, can be used as an indicator of her ‘biological clock’.

Various other mechanisms may cause earlier depletion of a woman’s ovarian reserve, however, some remain unknown.  Known causes of a reduction in the ovarian reserve include ovarian surgery, autoimmune disorders, treatment of cancers such as chemotherapy or radiation.

Women over 35 can often battle to fall pregnant due to declining numbers of viable eggs and falling pregnant after 45 is very rare.

There are a number of other causes, these being:

  • Issues with ovulation – ovulation disorders can affect the ovaries, preventing them from releasing eggs. These often include disorders that are hormonal such as polycystic ovary syndrome (PCOS), which occurs when the ovaries are unable to release an egg. Another condition that entails having too much prolactin (the hormone responsible for stimulating the milk production of the breasts), may also disrupt ovulation. The menstrual cycle can also be adversely affected by too much of the thyroid hormone, known as hyperthyroidism, or too little, known as hypothyroidism. Other issues known to disrupt ovulation are excessive exercise, injury, tumours and eating disorders.

Endometriosis

  • Endometriosis - this condition can cause irregularities in menstruation but often does not manifest any symptoms whatsoever.  It is caused by endometrial tissue growth on the outside of the uterus, which can affect the function of the uterus, fallopian tubes and the ovaries. The tissue growing on the outside of the uterus is then trapped and cannot go anywhere, the uterine tissue inside the uterus is typically shed every month during the menstrual cycle, but the tissue that is trapped cannot be shed, therefore inflaming the surrounding body tissue, which can cause scar tissue to form inside the fallopian tubes. This scar tissue does not only form inside the fallopian tubes but also inside the abdomen and around the ovaries, distorting a woman’s natural anatomy.

    The treatment of endometriosis of the ovary, namely the removal of an endometrioma, or removal of benign ovarian cysts, or an oophorectomy (removal of a whole ovary) will cause a reduction in the ovarian reserve (the way in which doctors describe how many eggs are left at any one point in time).
  • Fallopian tube blockage or damage – this is usually caused due to the fallopian tubes being inflamed, a condition known as salpingitis. This is often the result of pelvic inflammatory disease (PID) typically caused by an STI (sexually transmitted infection), endometriosis or adhesions.
  • Cervical or uterine abnormalities – these abnormalities also include ones of the opening of the cervix, polyps inside the uterus or the actual shape of the uterus being abnormal. Benign tumours, being non-cancerous, forming in the uterine wall, are known as uterine fibroids and do not normally cause infertility through blocking the fallopian tubes, they are more likely to disrupt the fertilised egg, preventing it from being implanted.
  • Premature ovarian insufficiency (POI) – is when the ovaries no longer work and menstruation stops before the age of 40. The exact cause of this is often unknown, however, there are certain factors associated with it, these can include genetic disorders (such as carriers of Fragile X syndrome or Turner syndrome), immune system diseases, smoking, radiation and chemotherapy.
  • Early menopause - this is when menopause begins earlier than expected (between the ages of 48 and 52).
  • Cancer and cancer treatments – female reproductive cancers are known to severely impact fertility as well as the treatments of radiation and chemotherapy.
  • Pelvic adhesions – such as bands of scar tissue that can bind the organs after a pelvic infection, pelvic or abdominal surgery or appendicitis.
  • Lifestyle factors – these include smoking and obesity which may play a role in the development of infertility. 
  • Other conditions – these include medical conditions that are associated with the absence of menstruation, known as amenorrhea or delayed puberty. Celiac disease, badly controlled diabetes and autoimmune diseases, with lupus being one, can all affect a woman’s infertility as they result in the menstrual cycle being impacted. These can also include genetic abnormalities.

How is infertility diagnosed in women?

Fertility relies on the ovaries releasing eggs that are healthy. The reproductive tract needs to allow an egg to pass through into the fallopian tube and join the sperm in order to be fertilised. This egg, having been fertilised, then travels to the uterus to be implanted in the lining. Tests for fertility in women determine if there are any issues in the fertilisation process.

A physical exam is first conducted as well as a gynaecological evaluation followed by specific fertility tests that can include:

  • Hysterosalpingography – this evaluation looks at the state of the fallopian tubes and uterus for problems such as blockages. An injection of an X-ray contrast agent is administered into the uterus in order to take a specialised X-ray (known as a fluoroscopy) to see if the area is normal as well as to make sure that the injected fluid does pass out of the fallopian tubes (i.e. they are not blocked).
  • Ovulation testing – this is a blood test that measures hormone levels in order to see if the woman is ovulating.
  • Ovarian reserve testing – doctors may use a combination of blood tests and findings from the ultrasound of the ovary to determine the ovarian reserve.  These tests determine the egg quantity and quality of those that are available for ovulation: 

    • Ultrasound: The size of the ovary (ovarian volume) and the antral follicle count are determined using an ultrasound.  
    • Blood tests: FSH (Follicle Stimulating Hormone) and oestrogen levels on day 2 or 3 of the menstrual cycle, as well as AMH (Anti-Mullerian Hormone level), will also be done. AMH is a hormone that is secreted by the cells in the developing follicles (egg sacs).  
  • Imaging tests – these are typically pelvic ultrasounds to check for fallopian tube or uterine disease and provide access to the ovary to determine the size and follicle count at a particular time in the menstrual cycle. These can also include a hysterosonography, which is used if something cannot be viewed on a normal ultrasound. As mentioned, the ovarian volume (the size of the ovary), as well as the antral follicle count are both determined using the ultrasound.
  • Other hormonal testing – these tests determine the levels of the ovulatory hormones, including the hormones that control the reproductive processes, known as the pituitary hormones.

All of the above give an indication of the ovarian reserve and efficiency.

If indicated, testing can also include:

  • Laparoscopy – this is minimally invasive surgery which involves creating a small cut below the navel and then inserting a small and thin device to view and examine the ovaries, fallopian tubes and uterus. This test is able to pick up on scarring, endometriosis, blockages and more.
  • Genetic testing – this helps to find out if a genetic issue is the cause of infertility.
  • Hysteroscopy – this test is done based on the symptoms that may suggest infertility is the result of uterine or fallopian tube disease. In this test, the doctor will insert a small and lighted device through the cervix to view any abnormalities.

Symptoms of infertility in women

Symptoms are normally due to changes in the menstrual cycle, these can include:

  • Abnormal periods with either heavier or lighter bleeding
  • Periods stopping suddenly or never starting (amenorrhea)
  • Periods that are irregular (i.e. periods are longer or shorter than usual. For example, if your periods are more than 35 days apart this may indicate that you are not ovulating). 
  • Periods that are painful and cause cramping as well as back pain

Hormone-related symptoms can include:

  • Loss of sex drive
  • Dark hair growing on the chin, chest and lips
  • Thinning hair
  • Gaining or losing weight unintentionally
  • Heart palpitations
  • Heat intolerance (i.e. sweating or feeling unusually hot)
  • Cold intolerance
  • Pain during sex
  • Milky discharge from nipples (unrelated to breastfeeding)

What are the treatment options for infertility in women?

It may only be that one or two treatments are needed in order to restore fertility. However, in some cases, several treatments may be required. It is purely dependent on the symptoms and causes.

Bear in mind, that this does not necessarily mean that you will require assisted reproductive techniques, you may only require minor investigations and treatments for various hormone level imbalances. Examples of this include hormone treatments to assist in the regulation of thyroid or insulin levels to aid in achieving natural conception.

Some of these can include:

  • Using fertility drugs to stimulate ovulation – these are seen as the main treatment for infertility as the drugs can regulate or induce ovulation.
  • Intrauterine insemination (IUI) – in this treatment healthy sperm is placed directly into the uterus, at the same time that the ovary releases an egg needing to be fertilised.
  • Surgery that restores fertility –this can include a uterine septum or intrauterine scar tissue which can be removed through hysteroscopic surgery. Treatment for endometriosis is also done laparoscopically (minimally invasive surgery - MIS) to improve fertility outcomes.

Assisted reproductive technology, known as ART.

To further elaborate on treatment options, it is best to focus on assisted reproductive technology, known as ART.

This refers to the treatment where an egg and a sperm are handled by doctors and lab technicians to achieve pregnancy. IVF (in vitro fertilisation) is the most common kind of this technique.

IVF is conducted within one-month cycles. Your doctor is basically attempting to simulate the natural process of conception with a degree of medical enhancement. Normally, your brain will stimulate the ovary to produce an egg, in IVF, your doctor will administer ovarian stimulation drugs in order for mature eggs to be harvested for fertilisation. Therefore, instead of ovulation occurring inside of the body, your eggs are removed and the process of fertilisation is induced in a lab. Once the embryos (fertilised eggs) are five days old, at the same time that the uterus would normally be prepared to accept an embryo (or multiple embryos, usually up to three, if you so choose), your doctor will transfer the five-day old embryo/s back into the uterus.

If this works, it can result in a viable pregnancy, and sometimes more than one foetus being formed. Multiple births are often a reality with IVF.

There are also other techniques that are used in the IVF cycle involving both men and women, known as:

  • ICSI (intracytoplasmic sperm injection) – this involves injecting a healthy sperm directly into an egg that is mature. This technique is normally used when IVF cycles have not worked or semen quantity is poor.
  • ZIFT (zygote intrafallopian transfer) or GIFT (gamete intrafallopian transfer) - this involves collecting the sperm and the egg in a lab and quickly placing them into the fallopian tube.
  • Assisted hatching –this sounds like something that is done using hens and their eggs, however, this technique involves implanting the embryo (egg fertilised with sperm) into the endometrium (lining of the uterus/womb) by opening the outer cover of the embryo, known as hatching.
  • Donor sperm or eggs – most cases of ART are conducted using a woman’s own eggs and a man’s own sperm. There can sometimes be issues with the eggs or the sperm, in which case eggs, sperm or embryos can be used from an anonymous donor.
  • Surrogacy – for a woman whose uterus does not function correctly or needs to be removed for some medical reason (this is known as a hysterectomy ), the embryo can be placed in the uterus of a gestational carrier (also known as a ‘surrogate’) in order for a foetus to form. The gestational carrier carries the foetus to full term and the baby is given to the biological parents at birth.

Complications of fertility treatment in women

Every treatment has its risks and complications, with fertility treatments these can include:

  • OHSS (ovarian hyperstimulation syndrome) – this results in the ovaries swelling and becoming painful due to fertility medications that induce ovulation.
  • Multiple pregnancy –this is a common complication with IVF due to multiple embryos being inserted into the woman’s uterus. Legally, clinics in some countries are prohibited from inserting more than three embryos at one time.
  • Infection or bleeding – this is a rare risk associated with any invasive procedure.

Risk factors for infertility in men and women

Many risks for men and women are the same, these being:

  • Age - fertility declines with age, specifically from 30 years old in women and age 40 in men.
  • Smoking cigarettes and drug use (particularly cannabis) – reduces fertility and the benefits of fertility treatments. It is also a leading cause of erectile dysfunction and low sperm count.
  • Alcohol abuse – women should not drink any alcohol when pregnant. Alcohol can increase the risk of birth defects and can also result in low sperm count and infertility in both men and women.
  • Obesity – being overweight or obese can lower the sperm count in men and increase the risk of infertility in both sexes.
  • Being underweight – eating disorders such as bulimia or anorexia result in fertility issues in women.
  • Over or under exercising – in not exercising enough or exercising too much, women can suffer from ovulation issue resulting in infertility.

When to see the doctor

It is advised that women should see a doctor after a year of trying to have a baby if they are under 35 if they are over 35 they should see a doctor after six months.

Before consulting with a doctor, it is advised to write down any medications that are being taken. As well as your sexual history and term of trying to have a baby. Diet and exercise habits, body changes, and genetic issues will also need to be known.

A doctor may refer you to someone who specialises in infertility, known as a reproductive medicine specialist.  Tracking your menstrual cycles in order to assess what your cycles are like can be extremely helpful to your reproductive medicine specialist in the process of assessing your case.

Early diagnosis holds the most promise of correcting infertility. It is best to always listen to your body and take notice of any changes or issues.

What is the long-term outlook?

Infertility is a common issue that many men and women face in their lives. Coping with it and finding suitable treatments can often hold the promise of rectifying the situation. Speak to your doctor about any issues you may have and to begin treatment immediately.

 

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