Infertility: Introduction, Issues and Insights


Infertility: Introduction, Issues and Insights

Have you ever known somebody who struggled to conceive or is struggling? Have you ever been in a situation like this yourself or currently struggling with the same? Infertility affects both men and women and is classified as a disease of the reproductive system as per the WHO.

Infertility is a very common reproductive disease that millions of couples are struggling with. However due to social and other issues, it has not received as much space in our normal everyday discourse as it needs to. Infertility is also associated with many taboos and superstitions, hence the need for creating awareness about this topic becomes extremely important to understand and educate people scientifically about the same.

The WonderMoM team in collaboration with TeamOrchid Fertility Clinichas taken a step towards spreading awareness and educating our readers about the scientific and lesser-known aspects, causes and treatment of female infertility. Orchid Fertility, part of Waha healthcare and based in the heart of Dubai Healthcare City, sets the standard for quality fertility care across the United Arab Emirates. Orchid Fertility maintains a rigorous international quality standard having finest fertility expertise supported by cutting edge technology advancements balanced with genuine, compassionate care. The team at Orchid Fertility Clinic has over the years been successfully delivering evidence-based fertility treatment at international levels, providing couple’s the best chance of realizing their dream of having a healthy baby. Their holistic approach aims to balance the emotional, physical and mental aspects of couples’ life to aid infertility treatments along with diet, stress management and lifestyle improvement.

In the sections ahead, Dr Partha Sarathi Das, Deputy Medical Director, Consultant Reproductive Endocrinology and Infertility from Team Orchid Fertility Clinic gives detailed insights into the issues and treatment of female infertility. Dr Das has around 15 years of experience in tertiary care centers dealing with complex gynecological, infertility and genetic cases and have helped many couples achieve parenthood. He provides treatment options tailor-made and catering for each individual patient needs and working together with them to ensure optimum compliance and success.  

Dr. Partha Sarathi Das

Understanding Infertility

Infertility affects millions of people of reproductive age worldwide – and has an impact on their families and communities.  As per the WHO statistics, between 48 million couples and 186 million individuals live with infertility globally. Infertility can be primary or secondary. Primary infertility is when a pregnancy has never been achieved by a woman, and secondary infertility is when at least one prior pregnancy has been achieved.  

Female Infertility

Infertility in women is defined by the inability to become pregnant after a year of unprotected intercourse in women aged less than 35 years and after 6 months if the women’s age is greater than 35 years. Female infertility can be caused by problems with the ovaries, fallopian tubes, uterus, and hormones. The most non-modifiable important risk factor is age. There are fewer good eggs left in a woman with advancing maternal age and thereby, the chances of miscarriage and infertility are high. Smoking, drinking, stress, and drastic weight gain or loss can all have an impact on a woman’s ability to conceive and maintain a pregnancy.

Symptoms

The main symptom of infertility is the inability to get pregnant. A menstrual cycle that’s too long (35 days or more), too short (less than 21 days), irregular or absent can mean that you’re not ovulating. In some women infertility is also associated with complaints of acne or skin color changes which are indications of hormonal problems.

Causes

Every step of the human reproduction physiology must go smoothly in order for pregnancy to occur. The following are the steps in this procedure:

  • A developed egg is released from one of the two ovaries.
  • The fallopian tube picks up the egg and transports it to the uterus
  • Sperms swim up the cervix, into the uterus, and into the fallopian tube to fertilize the egg.
  • The fertilized egg moves to the uterus via the fallopian tube.
  • The fertilized egg (embryo) develops and implants to the inside of the uterus.

Any variation or abnormality in the above normal physiology process can result in infertility as mentioned below:

  • Tubal disorders such as blocked fallopian tubes or hydrosalpinx are caused by untreated sexually transmitted infections (STIs) or complications of unsafe abortion, postpartum sepsis or abdominal or pelvic surgery.
  • Uterine disorders which could be inflammatory in nature (such as infection like chronic endometritis or adenomyosis or endometriosis or a polyp), congenital in nature (such as septate uterus), or benign in nature (such as fibroids)
  • Disorders of the ovaries, such as polycystic ovarian syndrome, endometriosis or other cysts like dermoid cysts.
  • Disorders of the endocrine system causing imbalances of reproductive hormones. The endocrine system includes hypothalamus and the pituitary glands. Examples of common disorders affecting this system include pituitary tumors, hypopituitarism, thyroid dysfunction.
  • Endometriosis occurs when endometrial tissue that typically grows in the uterus implants and grows outside the uterus. This extra tissue growth and the surgical removal of it can reduce the ovarian reserve, cause scarring which can block fallopian tubes and hydrosalpinx and keep an egg and sperm from uniting.
  • Apart from this certain other risk factors can contribute to infertility such as age, smoking, obesity or underweight, genetic causes, excessive alcohol consumption, unhealthy lifestyle etc.

Why Addressing Infertility is important?

Infertility is a common issue, yet it can be difficult to discuss. Infertility can leave people feeling angry, sad ,stressed,and guilty. Infertility can be physically, emotionally, and financially painful. But there is reason to be optimistic.Infertility treatments such as medications,surgery,intrauterine insemination, and assisted reproductive technology (IVF) have all helped infertile couples have healthy pregnancies. Awareness regarding the issue of infertility can be created through the following measures:

  • Enhancing public understanding that infertility needs and deserves attention.
  • Ensuring that people trying to build a family know the guidelines for seeing a specialist.
  • Educating lawmakers about how infertility impacts people in their state.

Infertility is a topic that has been stigmatized for a long time. However, National Infertility Awareness Week (NIAW) encourages everyone in the community to raise awareness about this issue and tear down barriers for those who are experiencing fertility problems.  This year NIAW intended to send a message of support and solidarity to everyone in the infertility community with seven days of advocacy and awareness events planned across the country.

Treatment

Fertility treatment encompasses ART, assisted reproductive technology procedures as mentioned below:

Ovulation Induction and timed intercourse:

This is the simplest form of fertility treatment. On cycle day 2, pelvic scan is done to ensure no cysts in ovaries and after baseline hormones test, oral medications like clomiphene citrate or letrozole is advised from day 2 for 5 days depending on response. Serial scans are done to monitor follicular growth and ovulation is either tracked naturally or ovulation trigger is given to initiate ovulation followed my timed intercourse.

Artificial insemination or IUI:

In this process ovulation induction is usually done with oral medications like clomiphene citrate or letrozole followed by follicular tracking to check growth of follicle. Ovulation is triggered by HCG injection. On day of ovulation, husband provides his sperm sample which is processed in the laboratory and the processed washed semen sample is inseminated into the uterus close to opening of fallopian tubes. After procedure, hormonal support medications are given to support pregnancy if any and pregnancy test is done after 2 weeks.

IVF/ICSI:

In Vitro Fertilization (IVF) is one of the assisted reproductive technologies (ART) procedures that helps in tackling infertility problems and assists in achieving pregnancy.

IVF does not alter the natural process of conception and childbirth. It is only meant to ensure the sperms from the male partner successfully fertilize the ovum (eggs). We can do the standard conventional method like IVF where the sperms and egg are left alone in a petri dish to fertilize on their own or conduct ICSI wherein the sperms are injected directly inside the eggs.

This treatment is suggested to couples suffering from unique infertility complications, including:

Fallopian Tube Blockage: The fallopian tubes connect the uterus with the ovaries. It allows the sperms to swim and fertilize the egg in the fallopian tube. Fallopian tubal blockage creates problems in fertilization by preventing the sperm meeting the egg.

Endometriosis: It is a condition in which the lining of the uterine tissues called endometrium grows out of the uterus mostly in and around the ovaries in the pelvis, hindering the embryo implantation process. It can cause adhesions that can compromise the normal pregnancy physiology and creating an inflammatory environment hostile to early implantation.

Uterine Fibroids: The fibroids are benign tumors on the uterus walls, prevalent among women in reproductive age group. These tumors interfere in the implantation of embryos or the fertilization process or can even be a cause of miscarriage.

Ovulation Disorders: Ovulation disorder refers to an irregular release of eggs as per the menstrual cycle. In most cases, because the ovulation period is delayed the menstrual cycle length becomes abnormal. This is typically seen in women with PCOS or with diminished ovarian reserve.

Impaired Sperm Function: If the sperm count is low, has lower motility, and abnormal morphology, it fails to fertilize the egg. These problems are often termed male infertility factors and can affect younger and older males due to various reasons like smoking, alcohol or anatomical reasons like varicocele.

Genetic Disorders: If either partner has a genetic disorder, they are more likely to face infertility, implantation failure or repeated pregnancy loss.

How is the IVF/ICSI treatment performed?

The IVF cycle is carried out in a series of procedures that are planned individually. The entire treatment is executed in the following steps:

● Ovarian stimulation

In a normal menstrual cycle, only one egg is produced for ovulation. In contrast, in an IVF treatment, controlled ovarian stimulation is done with hormonal injections to grow all the follicles recruited for that cycle. Regular follicular scans are done till the follicles reach 17-18 mm diameter. The doctor keeps a constant watch on the blood tests and few other diagnostics to monitor egg production. On the last day of ovarian stimulation, a specific hormone injection is given to initiate the final follicle maturation.

● Egg Retrieval

The second step is egg harvesting under ultrasound guidance where all the follicles are aspirated to see if there are eggs to carry out the process of fertilization. This is done under anesthesia.

●  Insemination

The semen sample is obtained from the male partner and embryologist isolates healthy sperms under a microscope. The healthy sperms are now spread over the healthy eggs in a lab dish and kept in an incubator which is the conventional IVF technique or the egg is inseminated with sperm called ICSI, intracytoplasmic sperm injection.

●  Embryo Culture

The embryologist monitors and tracks the development of fertilized embryos until day 5 stage called blastocyst stage. Multiple embryos if generated can be frozen for future use. It is at this stage of day 5 blastocyst that the embryos can be biopsied for PGS, preimplantation genetic screening to select he normal form the abnormal embryo.

  • Embryo Transfer:

After screening and choosing a healthy embryo, it is implanted in the uterus for conception. The results may take at least two weeks to show on a UPT or confirmed after 10-12 days after embryo transfer through blood tests.

Still having doubts and queries regarding any aspect of infertility? Nothing to worry about, we are here for you, as part of our ongoing collaboration with Orchid team, we have an ‘Ask the Doctor’ section with Dr. Partha Sarathi Das in the upcoming edition to help clear all your doubts and queries on issues of infertility. Dr Partha would be generously answering all your issues, feel free to drop in your queries at [email protected].