The Team Of Competent specialists lead by Dr Jeyarani Kamaraj and nurses at Aakash Fertility Centre and Hospital are dedicated to conducting a thorough medical evaluation and review of medical history with each patient to determine the possible cause of infertility. In this you will find details about the many potential causes of infertility including the most common diagnoses such as –
Most often, a diagnosis will be established after the infertility evaluation and workup. Once your diagnosis has been established, your Doctor will work closely with you to outline a treatment plan tailored to meet your specific needs.
A normal adult women ovulates every 25 to 32 days. Ovulation is actually a process of maturing eggs that have been “resting” in the ovaries since birth. Each day throughout a woman’s life until she reaches menopause, a few eggs move from the “resting” state into an “active” state. Even though eggs attempt to become “active” continuously through childhood, they can not mature since there are no hormones to drive their development. Hormones that can allow the “activated” eggs to mature only become available after a women reaches puberty. Once the eggs begin to mature they compete with each other to become “the” egg that will ovulate. After eggs commit to the maturation process, there is no turning backwards, they either achieve successful ovulation or they die.
OVULATORY DYSFUNCTION CAUSES
PREMATURELY AGING OVARIES
Some women have irregular menstruation because their ovaries produce too much androgen (male hormones). These women are often overweight, and have a history of irregular periods, acne, and infertility. This syndrome has been called the Polycystic Ovary Syndrome (PCOS) or PCO, because of the multiple small follicle cysts that can be seen on ultrasound lined up just under the surface of the ovary. In some cases the excess male hormone does not represent PCO. The adrenal gland or the ovary may be sources of abnormal androgen production. Some of these conditions may be dangerous and require further investigation and treatment. Women who do have PCO are treated using specific medications like metformin etc . Sometimes two or more drugs can be used simultaneously. Your doctor will usually first give you medication to induce menses. After menstrual flow begins drugs are given to induce ovulation It is helpful to monitor the response to this treatment. Acceptable ways of monitoring range from following basal body temperature charts and urinary ovulation predictor kits to daily sonogram monitoring and blood tests.
The aging ovary is the most common cause of ovulatory problems. In the 10 years before menopause fewer and fewer eggs are present in the ovaries. When the remaining eggs fall below a critical level, cycles can become irregular. Eggs that mature during the last decade of reproductive life, are not as likely to establish a continuing pregnancy. For women who experience irregular cycles secondary to ovarian aging, it may be necessary to use much more fertility medication to achieve ovulation. At CHR we have a special program for Prematurely Aging Ovaries.
Physical or mental stress can result in ovulatory problems. It is not unusual for college or professional school students to stop ovulating. Extreme weight loss, exercise training, even preparation for a piano recital can all result in ovulatory problems. In many cases, these problems are temporary and normal cycling returns when the stressor is no longer present. For women with extreme weight loss an internist, reproductive endocrinologist and psychologist or psychiatrist are often all needed to help correct the problem. Although one could treat this type of anovulatory problem with fertility drugs, most people believe that it is safer and more effective to correct the underlying stressor.
If a woman has either an under active or over active thyroid (Hypo or Hyperthyroidism) ovulatory problems may occur. Proper treatment of the thyroid abnormality will often restore ovulation.
Prolactin is a pituitary hormone that is normally secreted during and after pregnancy to prepare a woman’s body to produce milk for her baby. Sometimes too much prolactin is secreted from the pituitary when a woman is not pregnant. Not surprisingly, women with this condition often begin to lactate. Discharge of milk and loss of menstruation are the major symptoms associated with this condition. In some cases menses do not stop, but cycles become irregular and there is a shorter interval between menses. Women with this condition need to have a CT scan or MRI to make sure their pituitary is normal. Although in the past these cases sometimes required pituitary surgery, today excess prolactin production can almost always be effectively treated with medication.
ABNORMAL OVARIAN DEVELOPMENT
Some women are born with ovaries that can not produce eggs. Women with this condition do not go through puberty and usually never have a period.
When it comes to reduced fertility, the cause lies with the man in approximately 30% of cases, and with the woman in another 30% of cases. Sometimes the problem is caused by a combination of medical problems in both you and your partner. Each of you may have a medical condition, which, in combination, can make it difficult for you to conceive as couple. Diagnostic tests are used to great success to identify underlying causes of reduced fertility, and treatments are available for many disorders. Unfortunately, in approximately 10% of cases, the underlying cause of the problem cannot be pinpointed.
The general causes of male infertility include reductions in the quality of the sperm and problems with ejaculation. Reduced sperm quality can be caused by a number of factors. But in contrast to women, hormonal problems are less frequently a cause of male subfertility. This section contains a broad overview including useful information regarding these and other disorders that might be contributing to your problems.
REDUCED SPERM QUALITY
Insufficient sperm cells and other seminal disorders might be caused by hormonal problems, anatomical problems, immunological problems or even environmental factors. The quality of the sperm cannot be ascertained with the naked eye. Only an analysis of a sperm sample in a laboratory (sperm analysis) will provide information about the quantity, the motility, the form and the vitality of the sperm cells in a man’s semen. In addition, the clotting, the inflammatory cells and the level of acidity can also be checked.
As a result of this analysis, a man might be given one of the following diagnoses:
There are no sperm cells in the semen. In some cases, sperm is still being produced in the testicles but there could be a blockage or defect that prevents the sperm entering the semen. This blockage may be congenital disorder in the development of the male reproductive system or caused by an infection.
The semen contains only a small amount of sperm cells.
This diagnosis is used if sperm cells with insufficient or low motility are hindering other healthy sperm cells in their attempt to reach the ovum.
The sperm cells are so malformed that the chance of fertilizing an egg is very low. Sometimes multiple abnormalities are identified in which case the classification becomes even more complicated.
There are many causes for reduced sperm quality. Below you can find a summary of the most common causes of sperm problems
Any blockage in the sperm ducts (vas deferens) or urinary tract hinders the sperm from actually being ejaculated. Such blockages are a common cause of infertility. They can be caused by infections (including sexually transmitted diseases - STDs) and can sometimes be reversed with the use of antibiotics thereby restoring fertility. If the obstruction is structural (physical), surgery or another procedure might be necessary. If the structural blockage cannot be cleared, then a biopsy or testicular puncture can be carried out to extract the sperm from the testicles.
Sometimes the sperm ducts may not have developed. In this instance, sperm production does occur, but due to the absence of sperm ducts, it is impossible for the sperm cells to be present in the seminal ejaculation. Without intervention, it would be impossible for such men to father a child. In addition, these men often have an increased chance of a genetic disorder, which may increase the chance of the child having cystic fibrosis.
Klinefelter’s syndrome is a hereditary disorder (congenital disorder of the sex chromosomes in the hereditary material) in men characterised by an absence of or insufficient sperm cells in the semen. It is caused by an extra X-chromosome (XXY instead of XY). In many cases, sperm is still produced in the testicles, which can be collected through a testicular biopsy or puncture. However because it is a hereditary disorder, affected men will be advised to consult a genetic specialist before trying to start a family. The reason for this is that some of the sperm will also pass on an extra X-chromosome, which means that the child could inherit the same disorder as the father. A chromosome test of the embryos - preimplantation diagnosis - is one of the options that can make it possible to have healthy children.
Another hereditary disorder is the so-called Y-deletion. If a man has very poor sperm quality, the cause might be a hereditary problem with the male Y chromosome. This can be identified by undergoing a blood test, and again, because this disorder is passed on to male offspring, genetic advice is essential.
If a male suffers from retrograde ejaculation, the sperm cells travel in the wrong direction when an ejaculation occurs ending up in the bladder instead of in the urinary tract. From an anatomical perspective, the sperm ducts join the urinary tract normally but the valves that regulate the flow of urine and semen through the urinary tract are defective. (If the system functions as it should, the valve between the bladder and the urinary tract contracts during an ejaculation, while the valve between the sperm duct and the urinary tract closes during urination.) This rare disorder is sometimes associated with diabetes or removal of the prostrate gland. Infertility treatment is usually based on assisted reproductive technology with the use of sperm cells recovered from the bladder after ejaculation. A catheter is placed in the bladder first to introduce a buffered salt solution and secondly to retrieve the buffer semen mixture after ejaculation. The solution is needed, as urine can be poisonous to the sperm. Alternatively, the man is asked to drink neutralizing fluid two hours before ejaculation. After ejaculation, the bladder is emptied normally and the urine semen mixture collected and processed in the laboratory.
ECTOPIC TESTIS (cryptorchidism)
The scrotum hangs on the exterior of the body because the sperm must be a few degrees cooler than normal body temperature. If the testicles do not drop into the scrotum within or around the first month after birth, fertility problems can arise. Ectopic testis can be surgically corrected, but permanent damage can arise if the testicles don’t drop during childhood. The corrective surgical intervention may in itself be damaging to future fertility.
Varicose veins can occur in the scrotum. It is not clear precisely how this affects fertility, but one general theory is that the veins increase the temperature in the testicles. This warmth weakens the sperm and hampers sperm production. Varicose veins can be surgically fused, but there is no general agreement regarding the value of this surgical intervention in relation to its impact on fertility.
The exact hormonal balance in the male body is critical for the normal functioning of the male reproductive system. Male infertility can develop if the body produces insufficient testosterone or gonadotropins, namely follicle stimulating hormone (FSH) and luteinizing hormone (LH). However, hormonal disorders affecting reduced sperm quality are not that common. Hormonal problems can either be traced back to the primary glands that produce the hormones or to the glands where the hormones exert their affects: hypothalamus, pituitary, thyroid, prostate and testicles. If one of these glands does not function properly, this can be problematic to either sperm production or to the milk-like nutritional fluids that make up the semen.
A common factor that leads to the absence of sperm in the ejaculate is previous male sterilization (vasectomy). Men who desire offspring (subsequently) can opt for restorative surgery, to reverse the effects of the vasectomy. The success of this procedure depends on how long ago the vasectomy was carried out. If the vasectomy was performed more than five years, there is a smaller chance that it can be reversed successfully. Moreover, the greater the intervening gap, the greater the chance that antibodies against the sperm cells will be produced, causing sperm clotting. Vasectomy reversal is an outpatient procedure consisting of rejoining the patient’s sperm ducts or directly attaching the sperm ducts to the epididymis. If the vasectomy has been carried out more than five years ago, or if the restorative surgery is unsuccessful, then there are methods for retrieving the sperm from the epididymis or testicles for use in in vitro fertilization (IVF) or ICSI.
Sperm can also be influenced by the immune system. As a result of trauma or an infection, the immune system may produce antibodies that envelop the sperm and cause clotting of the individual sperm cells.
To successfully become pregnant, regular sexual intercourse must take place during the days when a woman is fertile. If the man has problems achieving an erection and/or ejaculating, this will have a direct effect on the chance of becoming pregnant. Erection difficulties can become a problem, particularly in the later stages of life. In the case of sexual problems, help can be sought from a sexologist and sometimes medications are also prescribed. Making love “on command” due to the desire to have children often puts added pressure on both partners in their sexual relationship, adding to or creating sexual problems.
There are a number of general illnesses and diseases, which can interfere with the production of healthy sperm. Given that the process of sperm production takes approximately 3 months, the effect of diseases or illnesses is temporary in some cases in which case normal sperm function resumes in time. Untreated infections can cause structural damage or reduce the production of healthy sperm. Fever and the use of some medications can also negatively affect male fertility. Reduced fertility can also be an unfortunate side effect of many health conditions or diseases, including diabetes, cystic fibrosis and mumps. All diseases that are associated with an extended period of high fever can also lower sperm production. In general, however, the effects of fever are temporary in nature.
URINARY TRACT INFECTION (UTI)
Urinary tract infections are generally characterized by a stabbing pain during urination. Their cause and treatment is the same as for epididymitis. These diseases can be treated with antibiotics but, in conjunction with possible fever, can also have a negative effect on the sperm. This effect is often temporary.
SEXUALLY TRANSMITTED DISEASES (STD)
The risk of reduced fertility as a result of a STD is high, as appeared to be the case with epididymitis, but at least men in contrast to women more often have the “advantage” of being aware of symptoms so that treatment can be given. (Many STDs, such as gonorrhoea, frequently cause no symptoms at all in women.) Some infections can be resistant to drugs and treatment can take longer than expected. Many men can also have STDs with no noticeable symptoms (asymptomatic), such as chlamydia, ureaplasma or mycoplasma, which may or may not impact the fertility of the man. However treatment is essential as these diseases can obviously have a profound effect on the fertility of the female partner.
This is an infection that can interfere with the function of the epididymis (where the sperm are stored) and therefore with the production of healthy sperm. In the case of epididymitis, the testicles can swell up due to the infection, which often causes pain. Sexually transmitted diseases (STDs) are the most frequent causes of infections of the epididymis. A bacterial infection can usually be cured with antibiotics, yet sperm production may be permanently damaged. Mumps related orchitis occasionally occurs in young boys. This is an inflammation of the epididymis caused by the mumps virus. This can lead to fertility disturbances due to abnormal sperm later in life.
Serious illnesses, such as cancer, can have an enormous effect on many aspects of life, including fertility:
Chemotherapy and radiation treatment can damage or destroy the cells in the reproductive system.
Sterility is a side effect of many drugs used to treat cancer.
To treat the cancer it may be necessary to remove some of the reproductive organs, which will result in a damaged reproductive system.
On a more positive note, doctors and the medical establishment as a whole increasingly are aware of cancer patients’ desire to preserve their fertility. Many cancer patients arrange for sperm collection ahead of treatment. The sample can then be frozen until needed (cryopreservation).
Although age has a greater impact on women’s fertility than men’s, men should not ignore age as a factor that contributes to reduced fertility. Various changes can occur in the man as a result of increasing age. These include:
Reduced function of the testicles
Lower hormone levels
Reduced sperm production
Increased chances of ejaculation problem