/ Gyn & Fertility Centre
Infertility means not being able to get pregnant after one year of trying, or six months, if a woman is 35 or older. Women who can get pregnant but are unable to stay pregnant may also be infertile.
Pregnancy is the result of a process that has many steps. To get pregnant:
|•||A woman’s body must release an egg from one of her ovaries (ovulation).|
|•||The egg must go through a fallopian tube toward the uterus (womb).|
|•||A man’s sperm must join with (fertilize) the egg along the way.|
|•||The fertilized egg must attach to the inside of the uterus (implantation).|
Infertility can happen if there are problems with any of these steps
You should approach a fertility unit for help if the female partner is:
|•||Under 35 years of age and trying for more than 1 year.|
|•||Between 35 and 39 years and trying to conceive with adequately timed intercourse for a period of 6 months or more.|
|•||40 years or more and attempting a pregnancy for 3 months or more.|
We do this because we recognize that female age is one of the most important predictors of subsequent conception.
When female age is a factor, moving more aggressively towards completing the evaluation and initiating treatment can help to maximize the chances of pregnancy.
No, infertility is not always a woman’s problem. Both women and men can have problems that cause infertility. About one-third of infertility cases are caused by women’s problems. Another one third of fertility problems are due to the man. The other cases are caused by a mixture of male and female problems or by unknown problems
Infertility in men is most often caused by:
|•||A problem called varicocele. This happens when the veins on a man’s testicle(s) are too large. This heats the testicles. The heat can affect the number or shape of the sperm.|
|•||Other factors that cause a man to make too few sperm or none at all.|
|•||Movement of the sperm. This may be caused by the shape of the sperm. Sometimes injuries or other damage to the reproductive system block the sperm.|
Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. For example, cystic fibrosis often causes infertility in men.
A man’s sperm can be changed by his overall health and lifestyle. Some things that may reduce the health or number of sperm include:
|•||Heavy alcohol use|
|•||Environmental toxins, including pesticides and lead|
|•||Health problems such as mumps, serious conditions like kidney disease, or hormone problems|
|•||Radiation treatment and chemotherapy for cancer|
Most cases of female infertility are caused by problems with ovulation. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.
Ovulation problems are often caused by polycystic ovarian syndrome (PCOS). PCOS is a hormone imbalance problem which can interfere with normal ovulation. PCOS is the most common cause of female infertility. Primary ovarian insufficiency (POI) is another cause of ovulation problems. POI occurs when a woman’s ovaries stop working normally before she is 40. POI is not the same as early menopause.
Less common causes of fertility problems in women include:
|•||Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy|
|•||Physical problems with the uterus|
|•||Uterine fibroids, which are non-cancerous clumps of tissue and muscle on the walls of the uterus|
Many things can change a woman’s ability to have a baby. These include:
|•||Excess alcohol use|
|•||Being overweight or underweight|
|•||Sexually transmitted infections (STIs)|
|•||Health problems that cause hormonal changes, such as polycystic ovarian syndrome and primary ovarian insufficiency|
Many women are waiting until their 30s and 40s to have children. Age is a growing cause of fertility problems. About one-third of couples in which the woman is over 35 have fertility problems.
Aging decreases a woman’s chances of having a baby in the following ways:
|•||Her ovaries become less able to release eggs.|
|•||She has a smaller number of eggs left.|
|•||Her eggs are not as healthy.|
|•||She is more likely to have health conditions that can cause fertility problems.|
|•||She is more likely to have a miscarriage.|
Most experts suggest at least one year. Women 35 or older should see their doctors after six months of trying. A woman’s chances of having a baby decrease rapidly every year after the age of 30.
Some health problems also increase the risk of infertility. So, women should talk to their doctors if they have:
|•||Irregular periods or no menstrual periods|
|•||Very painful periods|
|•||Pelvic inflammatory disease|
|•||More than one miscarriage|
It is a good idea for any woman to talk to a doctor before trying to get pregnant. Doctors can help you get your body ready for a healthy baby. They can also answer questions on fertility and give tips on conceiving.
No type of food is related to infertility not even what called healthy foods, but foods which are rich in fats and carbohydrates can lead to obesity which in turn can cause ovulatory problems.
If your Body Mass Index (weight in Kg/ height in Meters) is below 26 then it is normal. 26-30 BMI is obese and above 30 is a cause of concern. Obesity is the cause of PCOS ovaries which cause ovulatory problems. Thus weight loss of at least 10% of your body weight is important.
Painful periods do not necessarily mean infertility. Regular painful periods are an indication of ovulatory cycles. However progressive pain before the menses or during the sexual act may signify endometriosis. Irregular menses should be investigated especially if you are obese.
Day 1 is the first day you see a red flow, not just intermittent spotting.
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).
Polycystic ovary syndrome (PCOS) is one of the most common causes of infrequent ovulation and irregular cycles in women. The exact cause is as yet unknown and in some cases may be genetic. In this syndrome, the ovaries produce an excess of androgens (male-type hormones) that prevent the egg from maturing normally, and the ovaries often have a multicystic appearance on ultrasound (hence the term polycystic ovaries) as a result of this arrest in maturation. Higher androgen production may also be associated with excess hair growth (hirsutism) on the face, chest, and abdomen. Because of fewer normal ovulations, women with PCOS often have difficulty conceiving. In addition, many patients with PCOS are resistant to the action of insulin and thus should be screened for diabetes.
Because ovulation is infrequent when PCOS is present, the uterine lining does not shed regularly. Women who don’t menstruate regularly are at increased risk for developing cancer of the lining of the uterus (endometrial cancer). This can be prevented by treatment with a medication known as Provera®, which will induce a menstrual flow. Provera® is a tablet taken daily for 12 to 14 days every two or three months.
If a woman with PCOS wishes to conceive, ovulation can usually be stimulated with a medication known as clomiphene citrate. If this treatment is unsuccessful, injectable medications, called gonadotropins, may be necessary. Gonadotropins are very successful in inducing ovulation, though they are more often associated with multiple pregnancies than is clomiphene citrate.
Another treatment that has helped some patients is surgical “drilling” of the ovaries or wedge resection. This laparoscopic procedure temporarily reduces androgen production by the ovaries and may result in spontaneous ovulation or may improve the response of the ovaries to ovulation inducing medications.
There is no normality, but for a young couple 2-3 times a week is considered normal for conception to occur. The sexual act should be had in the fertile window of the menstrual cycle.
Lubrication can be used during a sexual act when one is not trying to conceive. I.e. one should not use any kind of lubrication during the fertile window.
Although there are no scientific tests to prove that stress causes infertility, all infertile patients are under stress, and it is infertility which causes the stress. It is important to note that many a patients have conceived if they are able to relax.
Blood groups have no correlation to infertility.
If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary, and you need a complete evaluation.
Doctors will do an infertility checkup. This involves a physical exam. The doctor will also ask for both partners’ health and sexual histories. Sometimes this can find the problem. However, most of the time, the doctor will need to do more tests.
In men, doctors usually begin by testing the semen. They look at the number, shape, and movement of the sperm. Sometimes doctors also suggest testing the level of a man’s hormones.
In women, the first step is to find out if she is ovulating each month. There are a few ways to do this. A woman can track her ovulation at home by:
|•||Writing down changes in her morning body temperature for several months|
|•||Writing down how her cervical mucus looks for several months|
|•||Using a home ovulation test kit (available at drug stores)|
Doctors can also check ovulation with blood tests. Or they can do an ultrasound of the ovaries. If ovulation is normal, there are other fertility tests available.
Finding the cause of infertility can be a long and emotional process. It may take time to complete all the needed tests. So don’t worry if the problem is not found right away.
For the male partner a semen examination with 4 – 5 days abstinence. For the female partner a day 2 or day 3 hormonal evaluation i.e. FSH, LH, Prolactin and TSH. A sonography in the form of ovulation studies is done from Day 9 of the cycle. However in some patients due to some clinical findings the doctor may ask for a laparoscopy/ hysteroscopy.
A routine gynecology examination does not provide all the probable causes of infertility. So you will need a schematic work up. Since 50% of infertility is due to a male factor, a simple semen examination will rule out a male factor. Later on, hormonal assays, a trans-vaginal sonography, a hysterosalpingography and if required alaparo/ hysteroscopy would be done.
A uterus which is bent backwards is known as a retroverted uterus and one in six ladies have it. It is not a cause of infertility and surgery is not advised.
Seminal fluid consists of secretions from test is, seminal vesicles and prostate. Producing a good volume or thick semen does not mean that the semen is normal. Semen examination should be done for sperm count & motility.
There is no simple drug treatment that can help in improving your semen quality. A good way that can help is goes through assisted reproductive technique.
Pelvic infections are the most common cause of tubal blocks. Chlamydia and genital tuberculosis are generally asymptomatic and hence may cause tubal blocks.
Tuberculosis is the most common transmittable disease. One can contract – harbor this disease at any point in life. The disease may manifest when the Hosts’ immunity status is low for any reason. Since it is a completely curable disease one should not have a taboo but treat it as per the doctor’s advice.
Infertility can be treated with medicine, surgery, artificial insemination, or assisted reproductive technology. Many times these treatments are combined. In most cases infertility is treated with drugs or surgery.
Doctors recommend specific treatments for infertility based on:
|•||How long the couple has been trying to get pregnant|
|•||The age of both the man and woman|
|•||The overall health of the partners|
|•||Preference of the partners|
Doctors often treatinfertility in men in the following ways:
|•||Sexual problems: Doctors can help men deal with impotence or premature ejaculation. Behavioral therapy and/or medicines can be used in these cases.|
|•||Too few sperm: Sometimes surgery can correct the cause of the problem. In other cases, doctors surgically remove sperm directly from the male reproductive tract. Antibiotics can also be used to clear up infections affecting sperm count.|
|•||Sperm movement: Sometimes semen has no sperm because of a block in the man’s system. In some cases, surgery can correct the problem.|
In women, some physical problems can also be corrected with surgery.
A number of fertility medicines are used to treat women with ovulation problems. It is important to talk with your doctor about the pros and cons of these medicines. You should understand the possible dangers, benefits, and side effects.
Some common medicines used to treat infertility in women include:
|•||Clomiphene citrate (Clomid): This medicine causes ovulation by acting on the pituitary gland. It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation. This medicine is taken by mouth.|
|•||Human menopausal gonadotropin or hMG (Repronex, Pergonal): This medicine is often used for women who don’t ovulate due to problems with their pituitary gland. hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.|
|•||Follicle-stimulating hormone or FSH (Gonal-F, Follistim): FSH works much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.|
|•||Gonadotropin-releasing hormone (Gn-RH) analog: These medicines are often used for women who don’t ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.|
|•||Metformin (Glucophage): Doctors use this medicine for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.|
|•||Bromocriptine (Parlodel): This medicine is used for women with ovulation problems due to high levels of prolactin. Prolactin is a hormone that causes milk production.|
Many fertility drugs increase a woman’s chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born too early (prematurely). Premature babies are at a higher risk of health and developmental problems.
A lead follicle should be at least 18 mm before you can have your hCG shot. The hCG will induce the follicle to ovulate after 36 hours.
Assisted reproductive technology (ART) is a group of different methods used to help infertile couples. ART works by removing eggs from a woman’s body. The eggs are then mixed with sperm to make embryos. The embryos are then put back in the woman’s body.
Common methods of ART include:
|•||In Vitro Fertilization (IVF) means fertilization outside of the body. IVF is the most effective ART. It is often used when a woman’s fallopian tubes are blocked or when a man produces too few sperm. Doctors treat the woman with a drug that causes the ovaries to produce multiple eggs. Once mature, the eggs are removed from the woman. They are put in a dish in the lab along with the man’s sperm for fertilization. After 3 to 5 days, healthy embryos are implanted in the woman’s uterus.|
|•||Intrauterine Insemination(IUI) is the process of preparing and delivering sperm so that a highly concentrated amount of active motile sperm is placed directly through the cervix into the uterus. IUI is typically performed with fertility drugs for the female patient. Thus, for infertility patients, IUI is commonly performed as a low-tech, cost-effective approach to enhancing fertility in patients. Prior to initiating IUI treatment, women must have at least one documented open fallopian tube as demonstrated by a hysterosalpingogrphy.|
|•||Intra-cytoplasmic Sperm Injection (ICSI) is often used for couples in which there are serious problems with the sperm. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg. Then the embryo is transferred to the uterus or fallopian tube.|
When we discuss IVF with women over 40, we feel it’s important to clearly and honestly inform them of their chances for success. Because we know that fertility declines significantly with age, largely due to a decline in egg quality, it’s only fair that women over 40 understand the statistics. In our program, delivery rates are between 18 percent and 30 percent for women in their mid to late 30s, and about 15 percent for women 40 and 41 years of age. In our experience, it is very uncommon for women over 42 to conceive with their own eggs. We also routinely recommend assisted hatching for these patients as pregnancy rates have been shown to improve with this treatment.
For most men, a 2-3 day break is ideal. This period gives the “sample” an opportunity to regenerate. Too “old” a sample raises the risk of poor motility, white cells, and other problems of “old” sperm. (An “old” sample would be one that is taken after more than 7 days of abstinence).
Admission is not necessary for IVF cycle as both egg-pick-up and embryo transfer, are outpatient procedures.
You can carry on your normal activities (including working) during IVF stimulation program. But once the embryo is transferred back, you should have more rest. Heavy lifting, climbing and long journey of walking should be avoided. No bed-rest is required unless advised by your doctor.
|•||Heavy exercise like: aerobics, jogging, weight lifting are prohibited during ovarian stimulation until the pregnancy test results are known.|
|•||Smoking / alcohol consumption should also be avoided during stimulation.|
|•||If a lady is under some medical treatment, please consult the doctor whether prescribed medicine are safe during stimulation protocol. As some medications may interfere with the fertility medication.|
As IVF cycle may be an emotional and stressful time for some couple, it may be helpful for a lady to talk to a supportive person like friend or a close family member. She can also take a help from counselor from the fertility clinic.
The miscarriage rate is about the same for ART as the general population. Since for ART patient we observe fetal sac in early stage, we often know about spontaneous miscarriages in the very early stages of pregnancy. These miscarriages probably go unnoticed in the general population.
Fertilization rates for ICSI: Most IVF programs see that about 70-85% of eggs injected using ICSI become fertilized. We call this the fertilization rate, which is different from the pregnancy rate.
Pregnancy success rates for in vitro fertilization procedures with ICSI have been shown in some studies to be higher than for IVF without ICSI. This is because in many of the cases needing ICSI the female is relatively young and fertile (good egg quantity and quality) as compared to some of the women having IVF for reasons other than male factor infertility. Another way to say this is – average egg quantity and quality is usually better in ICSI cases (male factor cases) because it is less likely that there is a problem with the eggs – as compared to cases with unexplained infertility in which there is more probability of a somewhat reduced egg quantity and quality (on the average, since some women in this group have egg related issues).
ICSI success rates vary according to the specifics of the individual case, the ICSI technique used, the skill of the individual performing the procedure, the overall quality of the laboratory, the quality of the eggs, and the embryo transfer skills of the infertility specialist physician performing the procedure.
Candidates for pre-implantation genetic diagnosis (PGD) are couples who have already had, or have been determined to be at high risk for having, a child with a known genetic disorder. It is important to realize that this procedure is not for the purpose of broad genetic screening. In order to detect problems, the embryologist must know what to look for. Conditions that are commonly tested for include Down syndrome, cystic fibrosis, Tay-Sachs, Thalassemia and sickle cell disease.