INFERTILITY: Investigations and Management in the 21st century
Written by
- Dr Lateef Akinola MSc, PhD, MBA, MRCOG
Consultant
Gynecologist & Fertility / IVF Specialist
INFERTILITY
is defined as the inability of a woman of reproductive age to get pregnant
after ONE YEAR of unprotected vaginal sexual intercourse, in the absence of any
known cause of infertility. It affects about 1 in 6 couples. The incidence is
about 10% to 15%, that is about 80 million couples are affected worldwide.
Known causes of infertility is probably equally distributed among the male and female
population.
Infertility
is associated with negative stigma, stress and often brings about family
disharmony. There are two types: PRIMARY INFERTILITY meaning that a woman has
never been able to conceive and SECONDARY
INFERTILITY where she has conceived at least once; with the pregnancy she
either has children, miscarriages or she had terminations. Infertility
treatment, across the world is very expensive, and largely not affordable by many
patients especially in low-resourced areas of the world including Africa, Asia
and other parts of the world.
Presently,
it is not advised for a woman to wait for ONE year or more in the presence of
pelvic infections, anovulation, polycystic ovaries syndrome, menstrual irregularities,
and endometriosis or in women with age over 35 years. Also prompt fertility
investigations and treatments are advised if the man have low sperm count and
other sperm abnormalities, impotence, un-descended testes and spermatic duct
blockages.
Causes of infertility
Among
the infertile couples, a third of infertility causes can be attributed to the
man, another third to the woman and the last third could be due to combination
of factors (attributable to both sexes), undefined or unexplained and other
causes like old age especially in the female, overweight/obesity or chronic
medical diseases (diabetes, tuberculosis poor dieting). Notable
causes of infertility in the females includes fibroid, infections /sexually
transmitted diseases (Chlamydia
and gonorrhea for example), blocked tubes, endometriosis and in the males
associated causes includes low sperm count, abnormally shaped sperm or absence
of sperm in the seminal fluid. The man could also be impotent, have retrograde
ejaculation or have blocked spermatic cord from past sexually transmitted
infections.
Stress and infertility
Infertility
is often associated with an unacceptable level of personal stress that could
manifest physically, and may be directed towards others at home, work and
within or outside the family. Stress affects couple’s relationship, reduces
libido and frequency of sexual intercourse. It also brings along ill health
which can worsens infertility and can also diminish success rates after
fertility treatment. There are a number of stress reducing processes out there
that are acceptable and can be tried. These include acupuncture, yoga, physical
exercise and herbal therapies to reduce stress, boost fertility and thereby
improve treatment successes. Of importance to note, is the fact that some of
the research evidence to support these therapies is neither robust nor
evidence-based.
Infertility: Principles of Care & Counseling
Infertility
counseling is a process during which a trained fertility counselor explains and
assists patients to explore and understand what is happening to them in relation
to their infertility. It is a useful process to allay the psychological effects
of fertility problems, and to give adequate and effective evidence-based information
in clear and concise ways. The methods of communications could be verbal,
written and audio visual, to help the couples make informed decisions about
fertility treatments as required. The
counselor and the patient often develop a mutual bond and understanding which
enable the patient to gain insight into his/her clinical situation regarding
infertility. Also the causal/associated factors specific to the patient and her
partner are explored in details. The counselor offers needed supports and
empathy. During the counseling process, mutually acceptable, workable and reasonable
routes to solutions are discussed including necessary details, which may be
followed by the patients. All these will be in a non-judgmental and
non-directive manner.
Initial detailed evaluation for husband and wife
An
adage says it takes two to tango, therefore, needless to say that during the
counseling and clinical evaluation the couples should be seen together. It is essential
during the initial and subsequent clinical evaluations that the couple seeking
fertility treatment should give relevant, factual and succinct information that
will be documented and will help the fertility doctor to proffer appropriate
treatment modalities for the couple. The couple must be reassured that all
information given and obtained will be kept in absolute CONFIDENCE. The
determinants of success following fertility treatments includes younger age,
previous history of pregnancy or successful fertility treatments, little or no
associated medical diseases, normal physical weight. Others include the cause
and of course the duration of infertility. A woman younger than 35 years of
age, with a normal body weight, with previous history of one or more
spontaneous pregnancies, children or successful fertility treatments and
without any confounding fertility impairing medical conditions (like
endometriosis, fibroids and chronic anovulation/polycystic ovarian syndrome)
are more successful than a woman that is older, with one or more
fertility-impairing diseases, obese and has never been pregnant before.
Therefore,
some pertinent questions and enquiries from the fertility specialist to answer
will include:
1. How many years the couple has been trying for baby?
2. Information on menstrual cycle, sexual activities and
contraceptive use
3. Information on previous pregnancies\outcomes and fertility
treatments (if any)
4. Information on medical diseases and surgical \ Gynecological
operations
5. Any previous sexually transmitted infections (and
treatments received)
6. Is the female partner current with her Pap smear?
7. The male\female partners’ personal or family history of
cancer – breast, ovarian and testicular will be asked.
8. Answers to important lifestyle inquiries like DRUGS intake
(past/present), SMOKING, ALCOHOL, OCCUPATION and DIET should be confidentially
disclosed to aid treatment planning.
9. In addition, information on personal and family history of
high blood pressure, diabetes; inherited family diseases of the brain, ovaries,
uterus (womb) and others are essential and should also be documented.
It
is pertinent to carry out complete general physical examination including the
genital organs on the wife and husband. The chest (heart, breathing, and breast)
and the abdomen examined for pain e.g. infections & swellings e.g.
fibroids. The height and weight of the individuals will be measured to calculate
the basal body mass index (BMI). The optimum BMI lies between 19 – 25 kg/m2. Laboratory
investigations – for the female and male couples will include:
MALE
Semen
analysis will be done to exclude any cause of abnormal or low sperm count in
the man. A minimum value for a normal semen analysis (WHO, 2010) will have a
volume of about 1.5 ml (1.4–1.7)
a sperm concentration of about 15 million per ml (12–16) therefore, a total
sperm number of about 39 million per ejaculate (33–46). The progressive
motility percent of the sperm cells will be about 32% (31–34), their vitality
percent around 58% live (55–63) and morphologically normal forms within 4.0%
(3.0–4.0). Causes
of sperm abnormalities include genetic (Klinefelter’s syndrome, Sertoli cell
syndrome), Undescended testes, varicocele, infection (tuberculosis, gonorrhea,
Mumps), prescribed or recreational drugs, poisons, scrotal heat and sometimes
unknown. Others causes of male infertility like diabetes, impotence and stress
are not uncommon. Therefore, the male partner should be screened for these and
for infections. Hormonal and/or genetic should not be left out, if required. Treatments
for any cause of sperm abnormalities are given as necessary usually by
consultants in the specialties of Andrology, genetics and reproductive
endocrinology, either alone or combined.
FEMALE
An
assessment of the ovarian reserve and evidence for ovulation with blood tests
are essential. Presently,
serum Anti Mullerian Hormone (AMH), Prolactin and Day 21 Progesterone are
measured. Nowadays,
this is what I usually do for my group of patients. AMH (is independent of the
menstrual cycle
and can be done at any time of the cycle) is now widely recommended to assess
ovarian reserve; it is evidently reported to be better than the routine measure
of ovarian reserve using serum level of follicle stimulating hormone (FSH)
which fluctuates widely and is dependent on the day of the menstrual cycle. Other
hormonal, genetic and laboratory investigations for the woman will be as
required and now depend on her clinical findings and situations. A pelvic
ultrasound scans to count egg-containing follicles and rule out ovarian
(cysts), uterine (fibroids) and other pelvic diseases e.g. tubal abscess or
hydrosalphinges is also necessary and will be done. Other important
investigations for the female partner will include screening for infections (HIV,
syphilis, hepatitis and chlamydia); assessing for tubal patency with Hydrosonograms
HyCoSy or Hysterosalpingogram (HSG); and for uterine abnormalities. If necessary
and depending on the clinical findings a surgical evaluation and treatment of
the woman including laparoscopic (abdomen/pelvic) and/or Hysteroscopic
(uterine) examinations are done.
What is NEW, USEFUL and ADVISED include appropriate LIFE-STYLE practices such as
2. It is recommended that couples should KEEP AWAY FROM SMOKING (which has detrimental fertility effects.
3. Limit Coffee, Tea, Cola and Chocolate consumption.
4. Maintenance of normal body weight, and avoidance of excessively low body weight & obesity (normal range of BMI 19 – 30 should be maintained). No surprise that women with significant anorexia nervosa and bulimia can have problems to conceive, because (in most cases) they have extremely low body weight for their age groups.
5. NO tight underwear or pants for men
6. Avoidance of testicular exposure to heat especially in such occupations involving prolonged bicycle\motorcycle rides, long distance lorry drivers and bakers.
7. Avoid unnecessary exposures to X-rays, heavy metals and pesticides.
8. Avoid DRUGS with adverse consequences on fertility especially over-the-counter and recreational drugs like cannabis, heroin and cocaine.
9. Engage in sensible use of VITAMINS & MINERALS – A, B, C, D, E, Zinc, Selenium, Folic acid.
10. Endeavor to eat Balanced DIET & Fruits
11. Engage in moderate physical exercise to keep your BMI within the normal range at around 19 to 25 kg/meter square.
Couples
are advised to engage in sexual intercourse every 2 to 3 days to significantly optimize
their chance of pregnancy. The rituals of timing sexual intercourse to coincide
with exact ovulation time can be very stressful and not recommended. Neither is
that of keeping a daily basal body temperature chart throughout the year, more
especially in the tropical environment like ours Africa\other parts of the
world, where daily temperatures can be over 30 degrees easily. The use of urinary
LH kits to determine fertile or ovulatory periods is expensive, often not
accurate and can be confusing.
Management of male infertility will
depend on the history and the clinical findings.
Abnormal
semen quality (for example when the man has no sperm at all or has low count)
can necessitate appropriate referrals to consultant specialists in Andrology,
reproductive endocrinology and infertility. In some instances hormonal
treatments may be recommended. A
number of fertility treatment modalities like SPERM DONATION and\or RETRIEVAL
of HUSBAND SPERM
from the testicular organs like percutaneous epidydimal sperm aspiration (PESA)
and testicular sperm aspiration (TESA) are available for in-vitro fertilization
(IVF) or intra-cytoplasmic sperm injection (ICSI) into the female eggs. In
spermatic tubal or ductal obstructions, testicular disease with low or no sperm
in the ejaculates, PESA and\or TESA techniques in combination with ICSI are
very useful. Infections are treated with appropriate antibiotics.
Life
style modifications like eating balanced diet and using diet supplements and
vitamins are useful. In
Varicoele; surgical treatment is presently controversial as there is currently
no robust evidence to support surgical treatments even though this is widely
practiced. In men with retrograde ejaculations of sperm into their urine (for
example those having chronic diabetes), there are a number of effective methods
for sperm harvesting from the urine immediately after sexual intercourse. The
harvested sperm can be used successfully for fertility treatments. Impotence
has several arrays of causal factors most especially including psychological,
stress induced and in chronic medical conditions like diabetes. Some of these
conditions are treatable with success using appropriately recommended
specialist drugs like Viagra and other mechanical methods of causing sustained
penal erection and to effect ejaculation in order to obtain sperm samples for fertility
treatments. Occasionally, and as required, especially in difficult cases
referrals for psychosexual therapies are essential part of treatments to
overcome impotence.
Management of female infertility will also depend on
clinical findings
Life- style activities e.g. smoking and alcohol drinking deteriorates fertility
and reduces success in fertility treatments, these should be stopped or at most
significantly curtailed for fertility potential amelioration and to improve
successes of treatments given. Obesity is increasing in most societies. The
health and social costs\consequences of obesity to the individual, family and
the society are enormous. Fertility treatment success are limited and
successful pregnancies risks includes higher risks of operative deliveries,
wound infection, postpartum hemorrhage, prolonged risk of immobility and Venous
Thrombo-Embolism (VTE). Obesity is often associated with Polycystic Ovarian Syndrome
(PCOS), subfertility, advanced maternal age, diabetes and
hypertension\preeclampsia with greater adverse maternal risks of pregnancy and
post-delivery. The
patients are strongly encouraged to get involved in better/effective weight
reduction strategies (including modifications of diet as advised by a qualified
dietician and engagement in physical exercise in moderation) to keep the BMI
within the normal range to improve treatment successes (Norman et al., 2004,
Sacks et al., 2009).
Maternal age
The
optimal female reproductive age in women is estimated to be between 19-25yrs.
There is increasing trend in voluntary age-related infertility as a result of postponement
of childbirth by a significant proportion of women of reproductive age for
career development, gains and economic empowerment. The consequences of this
situation are obvious. Older women have higher risks of infertility (as
infertility increases with advancing age) and exponential decline in egg
quality and quantity. Furthermore, the chances of requiring IVF to conceive are
significantly higher compared to younger women in the age bracket 20-30 years
and IVF treatments are associated with increased failures. Fertility
treatments including IVF, egg and embryo cryopreservation/storage, egg donation
and surrogacy are not the panacea to age-related decline in egg numbers,
quality or associated fertility problems later in life. Therefore, women are
advised not to unnecessarily delay child-bearing to avoid future
dissatisfactions and disappointments of unrealized fertility dreams and
potentials.
Paternal
age: Males are also not left out, as recent research publications have also
linked advanced male age to declining male fertility, higher chance of sperm
DNA fragmentation, increased risk of aneuploidies and congenital anomalies in
offspring.
Adjuvant therapies (AT) and fertility
Adjuvant
therapies are supplementary treatments given to women and men undergoing
fertility treatments with the aim of increasing pregnancy and live births
(Weiss et al., 2011). These therapies includes acupuncture, dietary
supplements, multivitamins, steroids, aspirin, anticoagulants like heparin,
various hormonal drugs (growth hormones, male hormones - DHEA) and Viagra. The benefits
and cost-effectiveness of most of these drugs (aside from their high expense)
are highly controversial. Therefore, for these reasons, the use of AT are
neither recommended nor widely practiced and any usage should be clinically
monitored and successes should be published to guide future uses. Ovulation
disorders are amenable to treatment with essential hormonal drugs including
clomiphene citrate tablets and injections of sex steroid hormones. These are
prescriptions drugs that should be prescribed and usage monitored during
fertility treatments by specialists only. They are associated with life
threatening complications like ovarian hyper stimulation syndrome and
multiple/higher order pregnancies. The medications can be used during monitored
ovulation inductions with timed sexual intercourse or artificial insemination with husband or donor sperm; and in IVF / ICSI treatment cycles. Artificial
insemination of sperm into the womb is indicated in women with treatable
ovulation disorders and\or unexplained infertility. It is NOT recommended for
women with tubal blockage and in men with moderate to severe sperm abnormalities
or men with no sperm at all.
Women
with fallopian tubal blockage are treated with either tubal microsurgery or
IVF. It is noteworthy, that recent evidence points to the fact that IVF processes
appears more cost-effective and more successes are recorded with IVF compared
to tubal microsurgery. In older women with significantly reduced egg reserve
EGG DONATION in combination with IVF is an acceptable treatment option. This
should be supported with strong DONOR POLICIES and CONSENT procedures to
prevent avoidable legal landmines. For those women with womb (uterus) diseases (fibroid,
Asherman syndrome, and congenital abnormally shaped womb) effective corrective surgeries
are available. Reproductive age women with functional ovaries, in whom the womb
has been surgically removed womb for treatment of cancer or other diseases and
in untreatable Asherman syndrome and in very rare congenital absence of the
womb (Rokitansky syndrome) IVF (using own/donor eggs ad applicable) and
SURROGACY are options to consider. For
now, there are no internationally agreed surrogacy laws. Surrogacy affords
opportunities for patients without a functional or congenitally absent womb and
in those repeated implantation failures to have children. The process is
fraught with significant emotional, social, moral, ethical, religious and legal
problems and controversies. It is, therefore, highly important to give
appropriate counseling before, during and after contractual surrogacy. This is
to prevent lasting and permanent psychological and emotional scarring to the
contractual partners and the children born through surrogacy.
When do we offer IVF? IVF
is best offered when indicated only. It can be done for MALE factors including
abnormally low or absence of sperm in ejaculates, after 3-4 failed artificial
inseminations and for FEMALE factors, notably fallopian tubal blockage, ovulation
disorders, unknown cause, repeated reproductive failures and in egg donation.
In combination with pre-implantation genetic diagnosis, IVF becomes very useful
in couples with repeated reproductive and/or implantation failures,
sex-selection and in most women of advanced reproductive age up to and above 37
years of age. Of
special mention is the fact that through the world, using the IVF processes,
about 5 million live births have been reported so far and in Nigeria it is
estimated that about 4,000 live births per year are delivered. Recent
technology and equipment advancements in IVF processes, drugs, and IVF expertise
have led to better outcomes and live births. The live birth rate has increased
significantly now and is up to 50% or more in well-established fertility clinics
like ours. Furthermore, pre-implantation genetic diagnosis (PGD) and Array
Comparative Genomic Hybridization (aCGH) are available for used to detect
genetically abnormal embryos before intrauterine transfer. By analyzing genetic
composition of cells biopsied from embryos PGD and aCGH allow couples
(especially with genetic abnormalities, repeated reproductive or implantation failures
and those with advanced maternal age wishing to use own eggs) all of whom have
high risk of having genetically disordered offspring to have a healthy child.
PGD usage has even been extended to include HLA tissue-typing for 'savior
siblings‘ in for example Fanconi’s anemia.
About the writer
Dr
Lateef Akinola is a consultant member of the Royal College of Obstetricians & Gynecologists
with full General Medical Council, UK and Nigerian Medical Council Specialist
registration in obstetrics & gynecology.
He has several years’ experience and hands-on track record in all
aspects of obstetrics and gynecology and specialization in reproductive
medicine and surgery including fertility and IVF. He worked as a consultant at
the Lincoln General Hospital and Luton and Dunstable hospitals in UK before
joining The London Women’s Clinic (a renowned private IVF Centre, Harley street
London). He is a member of the Society of Obstetrics and Gynecology of Nigeria,
British Fertility Society, European Society of Human Reproduction and
Embryology, and American Society for Reproductive Medicine. He has more than 30
publications in reputable scientific\medical journals to his credit. For more
information on his services go to www.fertilityassyst.com, www.pregnancythinking.com, www.themedisonhospital.com
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